LIBRARY OF CONGRESS. 



itt.. 



Shelf J?.!L£. 

IMTKII STATES OP AMERICA. 



A TEEATISE 



THE SCIENCE AND PRACTICE 



OF 



MIDWIFERY. 



/. BY 

W. S. PLAYFAIR,M.D.,F.R.C.P., 

PHYSICIAN- ACCOUCHEUR TO H. I. AND R. H. THE DUCHESS OF EDINBURGH ; PROFESSOR OF OBSTETRIC- 
MEDICINE IN KING'S COLLEGE; PHYSICIAN FOR THE DISEASES OF WOMEN AND CHILDREN TO 
KING'S COLLEGE HOSPITAL; CONSULTING PHYSICIAN TO THE GENERAL LYING-IN HOS- 
PITAL, AND TO THE EVELINA HOSPITAL FOR CHILDREN; LATE PRESIDENT 
OF THE OBSTETRICAL SOCIETY OF LONDON; EXAMINER IN MID- 
WIFERY TO THE UNIVERSITY OF LONDON AND TO 
THE ROYAL COLLEGE OF PHYSICIANS. 



FOURTH AMERICAN FROM THE FIFTH ENGLISH EDITION. 



| 0/ I WITH NOTES AND 

iLl^ by 



ADDITIONS 



^ 



ROBERT P. HARRIS, M.D. 



WITH THREE PLATES AND TWO HUNDRED AND ONE ILLUSTRATIONS. 




)lZo<r£&s 



PHILADELPHIA: 

LEA BROTHERS & CO 

1885. 



j~> M 



.9.1-u 



Entered according to Act of Congress, in the year 1885, by 

LEA BROTHERS & CO., 

in the Office of the Librarian of Congress at Washington. All rights reserved. 



Westcott it Thomson, William J. DoRNAN t 

Stereotype™ and Electrotypers, Philada. Printer. Philada. 



DEDICATION. 



TO 



THOMAS ADDIS EMMET, M.D., LL.D., 



AS A MARK OF 



PERSONAL ESTEEM, 



ADMIRATION FOR HIS MANY VALUABLE CONTRIBUTIONS 
TO MEDICAL SCIENCE. 



31 George Street, Hanover Square, 
March, 1885. 



AMERICAN PUBLISHER'S NOTICE. 



The Author has carefully revised this edition of his Treatise on 
Obstetrics, and presented the subject in its latest aspect from a British 
standpoint. It is well known, however, that American opinions and 
practice differ somewhat from those of Great Britain, and require that 
certain teachings should be remodelled in accordance with our usages 
and experience. We differ in the form of decubitus for the application 
of the forceps ; in the models of instruments in use ; in the measure of 
fear of the Csesarean operation when based upon our more favorable 
results; on the question of the use of stimulants for wet-nurses and 
convalescent parturient women, etc. 

During the several months that have elapsed since the publication of 
the English edition large additions have been made to our obstetrical 
statistics, and some changes effected in the management of cases requir- 
ing surgical assistance. The American Editor feels that he has been 
called upon to bring up his work to the latest period, and has therefore 
added the new forms of Cesarean operation devised in Germany, the 
experiences in Berlin with Hicks' method of treating placenta prsevia, 
the latest American statistics in the Cesarean section and laparo-elytro- 
tomy, the latest Porro statistics of the world, etc. He has also added 
articles on spondylolisthesis (a pregnant case of which is now in this 
city), the rational treatment of rupture of the uterus, etc. h\ all cases 
the additions have been distinguished by enclosure in brackets [ — ]. 

Philadelphia, March, 1885. 



AUTHOR'S PREFACE 



TO THE 



FOUETH AMERICAN EDITION 



In preparing a new edition of his work on Midwifery for his Ameri- 
can readers, the Author has gratefully to acknowledge the kind reception 
it continues to receive from the profession. A comparatively short time 
having elapsed since the last edition was published, there are naturally 
not many changes to make. The whole work, however, has been care- 
fully revised, and the chapter on " Conception and Generation " has been 
in great part rewritten, so as to incorporate the most recent advances in 
Embryology. The Author has to acknowledge the kind assistance he 
has received in this subject from his late colleague, Dr. W. Tyebell, 
Beookes, formerly of the Physiological Laboratory in King's College, 
now of Oxford. Several new illustrations have been added, and it is 
hoped that the work may thus prove more worthy of being used as a 
guide in the anxieties and emergencies of obstetric practice. 

31 George Street, Hanover Square, W., London, 
August, 1884. 



PREFACE TO THE FIRST EDITION. 



Those who have studied the progress of Midwifery know that there 
is no department of medicine in which more has been done of late years, 
and none in which modern views of practice differ more widely from 
those prevalent only a short time ago. The Author's object has been to 
place in the hands of his readers an epitome of the science and practice 
of midwifery which embodies all recent advances. He is aware that on 
certain important points he has recommended practice which not long 
ago would have been considered heterodox in the extreme, and which 
even now will not meet with general approval. He has, however, 'the 
satisfaction of knowing that he has only done so after very deliberate 
reflection, and with the profound conviction that such changes are right 
and that they will stand the test of experience. He has endeavored to 
dwell especially on the practical part of the subject, so as to make the 
work a useful guide in this most anxious and responsible branch of the 
profession. It is admitted by all that emergencies and difficulties arise 
more often in this than in any other branch of practice ; and there is no 
part of the practitioner's work which requires more thorough knowledge 
or greater experience. It is, moreover, a lamentable fact that students 
generally leave their schools more ignorant of obstetrics than of any 
other subject. So long as the absurd regulations exist which oblige the 
lecturer on midwifery to attempt the impossible task of teaching obstet- 
rics in a short three months' course — an absurdity which has over and 
over again been pointed out — such must of necessity be the case. This 
must be the Author's excuse for dwelling on many topics at greater 
length than some will doubtless think their importance merits, since he 
desires to place in the hands of his students a work which may in some 
measure supply the inevitable delects of his Lectures. 



viii PREFACE TO THE FIRST EDITION. 

Many of the illustrations are copied from previous authors, while 
some are original. The following quotation from the preface to Tyler 
Smith's Manual of Obstetrics will explain why the source of the copied 
wood-cuts has not been in each instance acknowledged : " When I began 
to publish, I determined to give the authority for every wood-cut copied 
from other works. I soon found, however, that obstetric authors of all 
countries, from the time of Mauriceau downward, had copied each other 
so freely without acknowledgment as to render it difficult or impossible 
to trace the originals." 

The Author has to express his acknowledgments to many friends for 
their kind assistance by the loan of illustrations and otherwise, and more 
especially to his colleague, Dr. Hayes, for his valuable aid in passing 
the work through the press. 

31 George Street, Hanover Square, 
March, 187G. 



CONTENTS 



PAET I. 

ANATOMY AND PHYSIOLOGY OF THE ORGANS CONCERNED 
IN PARTURITION 



CHAPTER I. 

ANATOMY OF THE PELVIS. 

PAGE 

Its importance — Formation of the Pelvis — The os innominatum : its three divis- 
ions — Separation between the True and False Pelvis — The Sacrum and Coc- 
cyx — Mechanical relations of the Sacrum — Pelvic articulations and ligaments 
— Movements of the Pelvic Joints — The Pelvis as a whole — Differences in the 
Two Sexes — Measurements of the Pelvis — Its diameters, planes, and axes — 
Development of the Pelvis — Soft parts in connection with the Pelvis ... 33 

CHAPTER II. 

THE FEMALE GENERATIVE ORGANS. 

Division according to Function : 1. External or Copulative ; 2. Internal or Forma- 
tive Organs — Mons Veneris — Labia majora and minora — The Clitoris — The 
Vestibule and Orifice of Urethra — Passing of the female catheter— Orifice of 
Vagina— The Hymen — The glands of the Vulva — The Perineum— The Vagina 
— The Uterus: its position and anatomy — The Ligaments of the Uterus— The 
Parovarium — The Fallopian Tubes— The Ovaries— The Graafian Follicles and 
the Ova — The Mammary Glands 49 

CHAPTER IK. 

OVULATION AND MENSTRUATION. 

Functions of the Ovary — Changes in the Graafian Follicle: 1. Maturation; 2. 
Escape of the Ovum — Formation of the Corpus Luteum — Quality and source 
of the Menstrual blood — Theory of Menstruation — Purpose of the Menstrual 
loss — Vicarious Menstruation — Cessation of Menstruation <S1 



COy TENTS. 

PART II. 

PREGNANCY. 



CHAPTER T. 

CONCEPTION AND GENERATION. 

PAGE 

The Semen — Site and mode of Impregnation — Changes in the Ovum — Cleavage 
of the Yelk — The Decidua and its formation — Formation of the Amnion — The 
Umbilical Vesicle and Allantois — The Liquor Amnii and its uses — The Cho- 
rion — The Placenta : its formation, anatomy, and functions 95 

CHAPTER II. 

THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 

Appearance of the Foetus at various stages of development — Anatomy of the Foetal 
Head— The Sutures and Fontanelles — Influence of Sex and Race on the Foe- 
tal Plead — Position of the Foetus in utero — Functions of the Foetus — The Foetal 
Circulation 118 

CHAPTER III. 

PREGNANCY. 

Changes in the form and dimensions of the Uterus — Changes in the Cervix — 
Changes in the texture of the Uterine Tissues, the Peritoneal, Muscular, and 
Mucous Coats — General modifications in the Body produced by Pregnancy . 132 

CHAPTER IV. 

SIGNS AND SYMPTOMS OF PREGNANCY. 

Signs of a fruitful Conception — Cessation of Menstruation— Sympathetic Disturb- 
ances; Morning Sickness, etc. — Mammary Changes — Enlargement of the Ab- 
domen— Quickening — Intermittent Uterine Contractions — Vaginal Signs of 
Pregnancy— Ballottement, etc. — Auscultatory Signs of Pregnancy— Foetal Pul- 
sations — Uterine Souffle, etc 143 



CHAPTER V. 

THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY— SPURIOUS PREGNANCY-TI1E 
DURATION OP PREGNANCY— SIGNS OF RECENT PREGNANCY. 

Adipose enlargement of the Abdomen— Distension of the Uterus by retained 

Menses, etc Congestive enlargement of the Uterus — Ascites — Uterine and 

Ovarian Tumors — Spurious Pregnancy: its Causes, Symptoms, and Diagnosis 

The Duration of Pregnancy — Sources of Fallacy — Methods of Predicting 

Date of Delivery — Protraction of Pregnancy — Signs of recent Delivery . . 157 



CONTENTS. xi 

CHAPTER VI. 

ABNORMAL PREGNANCY, INCLUDING MULTIPLE PREGNANCY, SUPER-FGETATION, 
EXTRA-UTERINE FCETATION, AND MISSED LABOR. 

PAGE 

Plural Births, their frequency : Relative frequency in different Countries ; 
Causes, etc.— Super-fetation and Super-fecundation — Nature — Explanation — 
Objections to admission of such cases — Their possibility admitted — Extra- 
uterine Pregnancy — Classification — Causes — Tubal Pregnancies — Changes in 
the Fallopian Tubes — Condition of Uterus — Progress and Termination — Diag- 
nosis — Treatment — Abdominal Pregnancy : Description ; Diagnosis ; Treat- 
ment — Missed Labor: its Symptoms, Causes, and Treatment 166 



CHAPTER VII. 

DISEASES OF PREGNANCY. 

Some only Sympathetic, others Mechanical or Complex in their Origin — Derange- 
ments of the Digestive Organs: Excessive Nausea and Vomiting; Diarrhoea; 
Constipation ; Hemorrhoids ; Ptyalism ; Dyspnoea, etc. — Palpitation — Syncope 
— Anaemia and Chlorosis — Albuminuria 198 



CHAPTER VIII. 

DISEASES OF PREGNANCY {continued). 

Disorders of the Nervous System : Insomnia ; Headaches and Neuralgia ; Par- 
alysis ; Chorea ; Disorders of the Urinary Organs ; Retention of Urine ; Irri- 
tability of the Bladder; Incontinence of Urine ; Phosphatic Deposits; Leucor- 
rhcea ; Effects of Pressure ; Laceration of Veins ; Displacements of the Gravid 
Uterus ; Prolapse, Anteversion, Retroversion — Diseases co-existing with Preg- 
nancy: Eruptive Fevers — Small-pox, Measles, Scarlet Fever, Continued Fever; 
Phthisis ; Cardiac Disease ; Syphilis ; Icterus ; Carcinoma ; Pregnancy compli- 
cated with Ovarian and Fibroid Tumors 211 



CHAPTER IX. 

PATHOLOGY OF THE DECIDUA AND OVUM. 

Pathology of the Decidua — Hydrorrhcea Gravidarum — Pathology of the Chorion ; 
Vesicular Degeneration, Myxoma Fibrosum —Pathology of the Placenta ; Blood 
Extravasations, Fatty Degeneration, etc. — Pathology of the Umbilical Cord — 
Pathology of the Amnion, Hydramnios; Deficiency of Liquor Amnii, etc. — 
Pathology of the Foetus : Blood Diseases transmitted through the Mother, 
Small-pox, Measles, and Scarlet Fever, Intermittent Fevers, Lead-poisoning, 
Syphilis — Imflammatory Diseases— Dropsies — Tumors— Wounds and Injuries 

of the Foetus — Intra-uterine Amputations — Death of the Foetus 226 

2 



xu CONTENTS. 

CHAPTER X. 

ABORTION AND PREMATURE LABOR. 

PAGE 

Importance and Frequency — Definition and Classification — Frequency — Recur- 
rence — Causes — Causes referable to Foetus — Changes in a Dead Ovum retained 
in Utero — Extravasations of Blood — Moles, etc. — Causes depending on Mater- 
nal State — Syphilis : Causes acting through Nervous System, Physical Causes, 
etc. — Causes depending on Morbid States of Uterus — Symptoms — Preventive 
Treatment— Prophylactic Treatment — Treatment when Abortion is inevitable 
— After-treatment 242 



PART III, 

LABOR. 



CHAPTER I. 

THE PHENOMENA OF LABOR. 

Causes of Labor — Mode in which the Expulsion of the Child is effected — The 
Uterine Contraction — Mode in which the Dilatation of the Cervix is effected — 
Rupture of the Membranes — Character and Source of Pains during Labor — 
Effect of Pains on Mother and Foetus — Division of Labor into Stages — Pre- 
paratory Stage — False Pains — First Stage — Second Stage — Third Stage — Mode 
in which the Placenta is expelled — Duration of Labor 255 

CHAPTER II. 

MECHANISM OF DELIVERY IN HEAD PRESENTATIONS. 

Importance of Subject — Frequency of Head Presentations — The Different Posi- 
tions of the Head — First Position — Division of Mechanical Movements into 
Stages — Flexion — Descent and Levelling Movement — Rotation — Extension — 
External Rotation— Second Position — Third Position — Fourth Position — Caput 
Succedaneum — Alteration in Shape of Head from Moulding 2G8- 

CHAPTER III. 

MANAGEMENT OF NATURAL LABOR. 

Preparatory Treatment — Dress of Patient during Pregnancy — The Obstetric Bag — 
Duties on first visiting Patient — False Pains — Their Character and Treatment 
— Vaginal Examination — The Position of Patient — Artificial Rupture of Mem- 
branes—Treatment of Propulsive Stage— Relaxation of the Perineum — Treat- 
ment of Lacerations— Expulsion of Child — Promotion of Uterine Contraction — 
Ligature of the Cord — Management of the Third Stage of Labor — Application 
of the Binder — After-treatment " 280 



CONTENTS. xiii 

CHAPTEE IV. 

ANESTHESIA IN LABOR. 

PAGE 

Agents employed — Chloral: its Object and Mode of Administration — Ether — 
Chloroform : its Use, Objections to, and Mode of Administration 295 



CHAPTER V. 

PELVIC PRESENTATIONS. 

Frequency — Causes — Prognosis to Mother and Child — Diagnosis by Abdominal 
Palpation and by Vaginal Examination — Differential Diagnosis of Breech, 
Knee, and Feet — Mechanism — Treatment — Management of Impacted Breech 
Presentations 299 



CHAPTER VI. 

PRESENTATIONS OF THE FACE. 

Erroneous Views formerly held on the Subject — Frequency — Mode of Production 
— Diagnosis — Mechanism — Four Positions of the Face — Description of Deliv- 
ery in First Face Position — Mento-posterior Position in which Rotation does 
not take place — Prognosis — Treatment — Brow Presentations 310 



CHAPTER VII. 

DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 

Causes of Face to Pubes Delivery — Mode of Treatment — Upward Pressure on 
Forehead — Downward Traction on Occiput — Use of Forceps — Peculiarities of 
Forceps Delivery 319 



CHAPTER VIII. 

PRESENTATIONS OF SHOULDER, ARM, OR TRUNK— COMPLEX PRESENTATIONS— PRO- 
LAPSE OF THE FUNIS. 

Position of the Foetus — Division into Dorso-anterior and Dorso-posterior Positions 
— Causes — Prognosis and Frequency — Diagnosis — Mode of distinguishing Po- 
sition of Child— Differential Diagnosis of Shoulder, Elbow, and Hand— Mech- 
anism — The Two Possible Modes of Delivery by the Natural Powers— Spon- 
taneous Version — Spontaneous Evolution — Treatment — Complex Presentation : 
Foot or Hand, with Plead, Hand, and Feet together— Dorsal Displacement of 
the Arm — Prolapse of the Umbilical Cord — Frequency — Prognosis Causes — 
Diagnosis — Postural Treatment — Artificial Reposition— Treatment when Re- 
position fails 322 



xiv CONTENTS. 

CHAPTER IX. 

PROLONGED AND PEECIPITATE LABORS. 

PAGE 

Evil Effects of Prolonged Labor — Influence of the Stage of Labor in Protraction — 
Delay in the First Stage rarely serious — Temporary Cessation of Pains — Symp- 
toms of Protraction in the Second Stage — State of the Uterus in Protracted 
Labor — Cases of Protraction due to morbid condition of the expulsive powers — 
Causes of Protraction — Treatment — Oxytocic Remedies — Ergot of Rye, etc. — 
Manual Pressure — Instrumental Delivery (case of Princess Charlotte of Waies) 
— Precipitate Labor — Its Causes and Treatment 337 



CHAPTER X. 

LABOR OBSTRUCTED BY FAULTY CONDITION OF THE SOFT PARTS. 

Rigidity of the Cervix : its Causes, Effects, and Treatment — Ante-partum Hour- 
glass Contraction — Bands and Cicatrices in the Vagina — Extreme Rigidity of 
the Perineum — Labor complicated Avith Tumor — Vaginal Cystocele — Calculus 
— Hernial Protrusions — (Edema of Vulva — Haematic Effusions, etc 351 

CHAPTER XL 

DIFFICULT LABOR DEPENDING ON SOME UNUSUAL CONDITION OF THE FOZTUS. 

Plural Births, Treatment of — Locked Twins — Conjoined Twins — Intra-uterine 
Hydrocephalus : its Dangers, Diagnosis, and Treatment — Other Dropsical 
Effusions — Foetal Tumors — Excessive Development of Foetus 363 

CHAPTER XII. 

DEFORMITIES OF THE PELYIS. 

Classification — Causes of Pelvic Deformity — Rickets and Osteo-malacia — The 
Equally-enlarged Pelvis — The Equally-contracted Pelvis — The Undeveloped 
Pelvis— Masculine or Funnel-shaped Pelvis — Contraction of Conjugate Diam- 
eter of the Brim — Figure-of-eight Deformity — Spondylolisthesis — Spondylo- 
lizema — Narrowing of the Oblique Diameters — Obliquely-contracted Pelvis — 
Kyphotic Pelvis — Robert's Pelvis — Deformity from Old-standing Hip-joint 
Disease — Deformity from Tumors, Fractures, etc. — Effects of Contracted Pelvis 
on Labor — Risks to the Mother and Child — Mechanism of Delivery in Head 
Presentation : a, in Contracted Brim ; 6, in Generally-contracted Pelvis— Diag- 
nosis — External Measurements — Internal Measurements — Mode of Estimating 
the Conjugate Diameter of the Brim — Mode of Diagnosing the Oblique Pelvis 
— Treatment — The Forceps — Turning — Craniotomy — The Induction of Pre- 
mature Labor — Induction of Abortion 375 



CHAPTER XIII. 

HEMORRHAGE BEFORE DELIVERY: PLACENTA PR.EYIA. 

Definition — Causes — Symptoms — Sources and Causes of Hemorrhage — Prognosis — 
Treatment 400 



CONTENTS. xv 

CHAPTER XIV. 

HEMORRHAGE FROM SEPARATION OF A NORMALLY-SITUATED PLACENTA. 

PAGE 

Causes and Pathology — Symptoms and Diagnosis — Prognosis — Treatment .... 411 

CHAPTER XV. 

HEMORRHAGE AFTER DELIVERY. 

Its Frequency — Generally a Preventible Accident — Causes — Nature's Method of 
controlling Hemorrhages — Uterine Contraction — Thrombosis — Secondary 
Causes of Hemorrhage — Irregular Uterine Contraction — Placental Adhesions 
— Constitutional Predisposition to Flooding — Symptoms — Preventive Treat- 
ment — Curative Treatment — Secondary Treatment — Secondary Post-partum 
Hemorrhage — Its Causes and Treatment 415 



CHAPTER XVI. 

RUPTURE OF THE UTERUS, ETC. 

Its Fatality — Seat of Rupture — Causes, Predisposing and Exciting — Symptoms — 
Prognosis — Treatment: when the Foetus remains in Utero; when the Fcetus 
has escaped from the Uterus — Lacerations of the Cervix — Recapitulation — 
Lacerations of the Vagina — Vesico- and Recto-vaginal Fistulas — Their Mode 
of Formation — Treatment 431 



CHAPTER XVII. 

INVERSION OF THE UTERUS. 

Division into Acute and Chronic Forms— Description — Symptoms — Diagnosis — 
Mode of Production — Treatment 442 



PART IV. 

OBSTETRIC OPERATIONS. 



CHAPTER I. 

INDUCTION OF PEEMATUEE LABOR. 

History — Objects — May be performed either on account of the Mother or Child — 
Modes of inducing Labor — Puncture of Membranes — Administration of Oxy- 
tocics — Means acting Indirectly on the Uterus — Dilatation of Cervix — Separa- 
tion of Membranes — Vaginal and Uterine Douches— Introduction of Flexible 
Catheter 1-19 



xvi CONTENTS. 

CHAPTEE II. 

TURNING. 

PAGE 

History — Turning by External Manipulation — Object and Nature of the Opera- 
tion — Cases Suitable for the Operation — Statistics and Dangers — Method of 
Performance— Cephalic Version — Method of Performance — Podalic Version — 
Position of Patient — Administration of Anaesthetics— Period when the Opera- 
tion should be Undertaken — Choice of Hand to be used — Turning by Bi-polar 
Method — Turning when the Hand is introduced into the Uterus — Turning 
in Abdomino-anterior Positions— Difficult Cases of Arm Presentation . . . 457 



CHAPTEE III. 

THE FORCEPS. 

Frequent Use of the Forceps in Modern Practice — Description of the Instrument 
— The Short Forceps — Its Varieties — The Long Forceps — Suitable to all Cases 
alike — Action of the Instrument — Its Power as a Tractor, Lever, and Compress- 
or — Preliminary Considerations before Operation — Use of Anaesthetics — De- 
scription of the Operation — Low Forceps Operation — High Forceps Operation 
— Possible Dangers of Forceps Delivery — Possible Eisks to the Child .... 472 



CHAPTEE IV. 

THE VECTIS— THE FILLET. 

Nature of the Vectis — Its Use as a Lever or Tractor — Cases in which it is Applica- 
ble—Its Use as a Eectifier of Malpositions— The Fillet— Nature of the Instru- 
ment — Objection to its Use 495 



CHAPTEE V. 

OPERATIONS INVOLVING DESTRUCTION OF THE FCETUS. 

Their Antiquity and History — Division of Subject — Nature of Instruments em- 
ployed— Perforator— Crotchet— Craniotomy Forceps — Cephalotribe— Forceps- 
saw— Ecraseur— Basilyst— Cases requiring Craniotomy— Method of Perforation 
— Extraction of the Head — Comparative merits of Cephalotripsy and Cranioto- 
my— Extraction by the Craniotomy Forceps— Extraction of the Body— Em- 
bryotomy — Decapitation and Evisceration 497 



CHAPTEE VI. 

THE CESAREAN SECTION— PORRO'S OPERATION— SYMPHYSEOTOMY. 

History of the Operation— Statistics— Results to Mother and Child— Causes requir- 
ing the Operation— Post-mortem Cesarean Section— Causes of Death after the 
Cesarean Section— Preliminary Preparation— Description of the Operation — 
New Forms of Operating— Subsequent Management— Porro's Operation— Sub- 
stitutes for the Cesarean Section— Symphyseotomy 511 



CONTENTS. xvn 

CHAPTER VII. 

LAPAEO-ELYTROTOMY. 

PAGE 

History — Nature of the Operation — Advantages over the Cesarean Section — Cases 
suitable for the Operation — Anatomy of the Parts concerned in the Operation — 
Method of Performance — Subsequent Treatment 529 

CHAPTER VIII. 

THE TKANSFUSION OF BLOOD. 

History — Nature and Object of the Operation — Use of Blood taken from the Lower 
Animals — Difficulties from Coagulation of Fibrin — Modes of Obviating them 
— Immediate Transfusion — Addition of Chemical Agents to prevent Coagula- 
tion — Defibrination of the Blood — Statistical Results— Possible Dangers of the 
Operation — Cases suitable for Transfusion — Description of the Operation — 
Schafer's Directions for Immediate Transfusion — Effects of Successful Trans- 
fusion—Secondary Effects of Transfusion 534 



PAKT V. 

THE PUERPERAL STATE. 



CHAPTER I. 

THE PUERPEKAL STATE AND ITS MANAGEMENT. 

Importance of Studying the Puerperal State — The Mortality of Childbirth — 
Alterations in the Blood after Delivery — Condition after Delivery — Nervous 
Shock — Fall of the Pulse — The Secretions and Excretions — Secretion of Milk 
— Changes in the Uterus after Delivery — The Lochia — The After-pains — Man- 
agement of Women after Delivery — Treatment of Severe After-pains — Diet 
and Regimen 546 

CHAPTER II. 

MANAGEMENT OF THE INFANT, LACTATION, ETC. 

Commencement of Respiration after the Birth of the Child — Apparent Death of 
the New-born Child — Its Treatment — Washing and Dressing the Child— Ap- 
plication of the Child to the Breast — The Colostrum and its Properties— Secre- 
tion of Milk — Importance of Nursing — Selection of a Wet-nurse— Manage- 
ment of Lactation — Diet and Regimen of Nursing Women — Period of Weaning 
— Disorders of Lactation — Means of Arresting the Secretion of Milk — Defective 
Secretion of Milk — Depressed Nipples — Fissures and Excoriations of tin- Nip- 
ples — Excessive Flow of Milk — Mammary Abscess — Hand-feeding — Causes of 
Mortality in Hand-feeding — Various Kinds of Milk — Method of Hand-feeding 557 



xvm CONTENTS. 

CHAPTER III. 

PUERPERAL ECLAMPSIA. 

PAGE 

Its Doubtful Etiology — Premonitory Symptoms — Symptoms of the Attack — Con- 
dition between the Attacks — Relation of the Attacks to Labor — Results to 
Mother and Child — Pathology — Treatment — Obstetric Management . . . .573 

CHAPTER IV. 

PUERPERAL INSANITY. 

Classification — Proportion of Various Forms — Insanity of Pregnancy — Predispos- 
ing Causes — Period of Pregnancy at which it Occurs — Type of Insanity — Prog- 
nosis — Transient Mania during Delivery — Puerperal Insanity (Proper) — Type 
of Insanity — Causes — Theory of its Dependence on a Morbid State of the Blood 
— Objections to the Theory — Prognosis — Post-mortem Signs — Duration — In- 
sanity of Lactation — Type — Symptoms — Of Mania — Of Melancholia — Treat- 
ment — Question of Removal to Asylum — Treatment during Convalescence . 582 

CHAPTER V. 

PUERPERAL SEPTICAEMIA. 

Differences of Opinion — Confusion from this Cause — Modern View of this Dis- 
ease — History— Its Mortality in Lying-in Hospitals — Numerous Theories as to 
its Nature — Theory of Local Origin — Theory of an Essential Zymotic Fever — 
Theory of its Identity with Surgical Septicaemia — Nature of this View — Chan- 
nels through which Septic Matter may be Absorbed — Character and Origin of 
Septic Matter often Obscure — Division into Auto-genetic and Hetero-genetic 
Cases — Sources of Self-infection— Sources of Hetero-genetic Infection — Influ- 
ence of Cadaveric Poison — Infection from Erysipelas — Infection from other 
Zymotic Diseases — Infection from Sewer Gas— Contagion from other Puerperal 
Patients — Mode in which the Poison may be Conveyed to the Patient — Con- 
duct of the Practitioner in relation to the Disease — Nature of the Septic Poison 
— Local Changes resulting from the Absorption of Septic Material — Channels 
through which Systemic Infection is Produced — Pathological Phenomena ob- 
served after General Blood-Infection — Four Principal Types of Pathological 
Change— Intense Cases without Marked Post-mortem Signs — Cases character- 
ized by Inflammation of the Serous Membranes — Cases characterized by the 
Impaction of Infected Emboli and Secondary Inflammation and Abscess — 
Description of the Disease — Duration — Varieties of Symptoms in Different 
Cases — Symptoms of Local Complications — Treatment 593 

CHAPTER VI. 

PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 

Puerperal Thrombosis and its Results — Conditions which favor Thrombosis — Con- 
ditions which favor Coagulation in the Puerperal State — Distinction between 
Thrombosis and Embolism — Is Primary Thrombosis of the Pulmonary Arte- 
ries possible? — History — Symptoms of Pulmonary Obstruction — Is Recovery 
possible — Causes of Death — Post-mortem Appearances — Treatment — Puerperal 
Pleuro-pneumonia : its Causes and Treatment 621 



CONTENTS. xix 

CHAPTER VII. 

PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 

PAGK 

Causes— Symptoms — Treatment 633 

CHAPTER VIII. 

OTHER CAUSES OF SUDDEN DEATH DURING LABOR AND THE PUERPERAL STATE. 

Organic and Functional Causes — Idiopathic Asphyxia — Pulmonary Apoplexy — 
Cerebral Apoplexy — Syncope — Shock and Exhaustion — Entrance of Air into 
the Veins 635 

CHAPTER IX. 

PERIPHERAL VENOUS THROMBOSIS (SYNS. : CRURAL PHLEBITIS; PHLEGMASIA DO- 
LENS; ANASARCA SEROSA; CEDEMA LACTEUM ; MILK LEG, ETC.). 

Nature — Symptoms — History and Pathology — Anatomical Form of the Thrombi 
in the Veins — Detachment of Emboli — Treatment 637 

CHAPTER X. 

PELVIC CELLULITIS AND PELVIC PERITONITIS. 

Two Forms of Disease — Variety of Nomenclature — Importance of Differential 
Diagnosis — Etiology — Connection with Septicaemia — Seat of Inflammation — 
Relative Frequency of the Two Forms of Disease — Symptomatology — Results 
of Physical Examination — Terminations — Prognosis — Treatment 644 



INDEX 653 



ILLUSTRATIONS. 



Plate I. — Section of a Frozen Body in the last months of Pregnancy (after 
Braune). Illustrating the Belations of the Uterus to the surrounding Parts, 
and the attitude of the Foetus, which is lying in the second Cranial Posi- 
tion Frontispiece 

Plate II. — Section of a Frozen Body at the termination of the First Stage of 
Labor (after Braune). Membranes unbroken ; Cervix fully dilated ; and the 
Head (in the Second Position) in the Pelvic Cavity Frontispiece 

Plate III. — Illustrations of the Corpora Lutea of Menstruation and Pregnancy 

(after Dalton) Facing page 81 

FIG. PAGE 

1. Os Innominatum 34 

2. Sacrum and Coccyx 35 

3. Section of Pelvis and Heads of Thigh-bones, showing the Suspensory Action 

of the Sacro-iliac Ligaments. (After Wood.) 37 

4. Outlet of Pelvis 39 

5. The Female Pelvis 40 

6. The Male Pelvis 40 

7. Brim of Pelvis, showing Antero-posterior, Oblique, and Conjugate Diameters . 41 

8. Transverse Section of Pelvis, showing the Diameters 42 

9. Planes of the Pelvis, with Horizon 43 

10. Axes of the Pelvis 44 

11. Representing General Axis of the Parturient Canal, including the Uterine 

Cavity and Soft Parts 45 

12. Side View of Pelvis 46 

13. Pelvis of a Child 47 

14. External Genitals of Virgin with Diaphragmatic Hymen. (After Sappey.). 49 

15. Vascular Supply of Vulva. (After Kobelt.) 53 

16. Bight Half of Virgin Vagina with Walls held apart, showing the abundant 

transverse Rugse, the greater depth of the Vagina above than below, and 

the Hymeneal Segment. (After Hart.) : > 1 

17. Longitudinal Section of Body, showing Relations of Generative Oruans . . . 55 

18. Transverse Section of Body, showing Relations of the Fundus Uteri .... 56 

19. Transverse Section of Uterus r, ~ 

20. Uterus and Appendages in an Infant. (After Farre.) 58 

21. Portion of Interior of Cervix. (Enlarged nine diameters. ) 59 

22. Muscular Fibres of unimpregnated Uterus. (After Farre.) 60 

23. Developed Muscular Fibres from the Gravid Uterus. (After Wagner.) . • • 60 

24. Lining Membrane of Uterus, showing network of Capillaries and Orifices of 

Uterine Glands. (After Farre.) 62 

25. The Course of the Glands in the fully-developed Mucous Membrane of the 

Uterus. (After Williams.) 62 

xx i 



xxii ILL USTRA TIONS. 

FIG. PAGE 

26. Vertical Section through the Mucous Membrane of the Human Uterus. 

(After Turner.) 63 

27. Villi of Os Uteri stripped of Epithelium. (After Tyler Smith and Hassall.) . 64 

28. Villi of Uterus, covered with Pavement Epithelium, and containing Looped 

Vessels. (After Tyler Smith and Hassall.) 64 

29. Bifid Uterus. (After Farre.) 66 

30. Partitioned Uterus. (Kussmaul.) 68 

31. Adult Parovarium, Ovary, and Fallopian Tube. (After Kobelt.) 69 

32. Posterior View of Muscular and Vascular Arrangements. (After Kouget.) . 70 

33. Fallopian Tube laid open. (After Richard.) 72 

34. Ovary enlarged under Menstrual Nisus 73 

35. Longitudinal Section of Adult Ovary. (After Farre.) 74 

36. Section through the Cortical part of the Ovary. (After Turner.) 75 

37. Vertical section through the Ovary of the Human Foetus. (After Foulis.) . 76 

38. Diagrammatic Section of Graafian Follicle 77 

39. Bulb of Ovary 78 

40. Mammary Gland 79 

41. Section of Ovary, showing Corpus Luteum three weeks after Menstruation. 

(After Dalton.) 83 

42. Corpus Luteum at the fourth month of Pregnancy. (After Dalton.) .... 84 

43. Corpus Luteum of Pregnancy at Term. (After Dalton.) 84 

44. Section of Parts of three Seminiferous Tubules of a Rat. (From a prepara- 

tion by Mr. A. Frazer.) 96 

45. Ovum of Rabbit containing Spermatozoa 97 

46. Formation of the "Polar Globule" ■. 99 

47. Segmentation of the Yelk . 99 

48. Formation of the Blastodermic Membrane. (After Joulin.) 100 

49. Aborted Ovum (of about forty days), showing the Triangular Shape of the 

Decidua (which is laid open), and the Aperture of the Fallopian Tube. 

(After Coste.) 102 

50.1 

51. [ Formation of the Decidua. (After Dalton.) 102 

52. j 

53. An Ovum removed from the Uterus, and part of the Decidua Vera cut away. 

(After Coste.) 103 

54. Diagram of Area Germinativa, showing the Primitive Trace and Area Pel- 

lucida 105 

55. Development of the Amnion 106 

56. Development of the Umbilical Vesicle and Amnion 107 

57. An Embryo of about twenty-five days laid open. (After Coste.) 107 

58. Development of the Chorion 108 

59. Placental Villus, greatly magnified. (After Joulin.) 113 

60. Terminal Villus of Foetal Tuft, minutely injected. (After Farre.) 113 

61. Diagram representing a Vertical Section of the Placenta. (After Dalton.) . 114 

62. Diagram illustrating the Mode in which a Placental Villus derives a Cover- 

ing from the Vascular System of the Mother. (After Priestley.) .... 115 

63. The Extremity of a Placental Villus. (After Goodsir.) 115 

64. Anterior and Posterior Fontanelles 121 

65. Bi-parietal Diameter, Sagittal and Lambdoidal Sutures, with Posterior Fonta- 

nelle 121 

66. Diameters of the Foetal Skull 122 



ILLUSTRATIONS. xxiii 

FIG. PAGE 

67. Mode of Ascertaining the Position of the Foetus by Palpation 124 

68. Diagram illustrating the Effect of Gravity on the Foetus. (After Duncan.) 126 

69. Illustrating the greater Mobility of the Foetus and the larger relative amount 

of Liquor Amnii in Early Pregnancy. (After Duncan.) 126 

70. Diagram of Foetal Heart. (After Dalton.) 129 

71. Diagram of Heart of Infant. (After Dalton.) 131 

72. Relations of Pregnant Uterus at six months. (After Martin.) 133 

73. Size of Uterus at various Periods of Pregnancy 135 

74. \ 

75. I Supposed Shortening of the Cervix at the third, sixth, eighth, and ninth 

76. [ months of Pregnancy, as figured in Obstetric Works 136 

77. J 

78. Cervix of a Woman Dying in the Eighth Month of Pregnancy. (After 

Duncan.) 137 

79. Appearance of the Areola in Pregnancy 147 

•80. Illustrating the Cavity between the Decidua Vera and the Decidua Reflexa 

during the early Months of Pregnancy. (After Coste.) 171 

81. Tubal Pregnancy, with the Corpus Luteum in the Ovary of the opposite side. 174 

82. Tubal Pregnancy. (From a specimen in the Museum of King's College.) . 175 

83. Extra-uterine Pregnancy at term of the Tubo-ovarian Variety. (After 

a case of Dr. A. Sibley Campbell's.) 177 

84. Uterus and Foetus in a case of Abdominal Pregnancy 184 

85. Lithopsedion. (From a preparation in the Museum of the Royal College of 

Surgeons.) 185 

86. Contents of the Cyst in Dr. Oldham's case of Missed Labor 194 

87. Hypertrophied Decidua laid open, with the Ovum attached to its Fundal 

Portion. (After Duncan.) 227 

88. Imperfectly developed Decidua Vera, with the Ovum. (After Duncan.) . . 228 

89. Hydatidiform Degeneration of the Chorion , 230 

90. Double Placenta, with Single Cord 233 

91. Fatty Degeneration of the Placenta 234 

92. Knots in the Umbilical Cord 235 

'93. Intra-uterine Amputation of both Arms and Legs 240 

94. An Apoplectic Ovum, with Blood effused in masses under the Foetal Surface 

of the Membranes 245 

95. Blighted Ovum, with Fleshy Degeneration of the Membranes 246 

96. Mode in which the Placenta is Naturally Expelled. (After Duncan.) . . . 266 

97. Attitude of Child in First Position. (After Hodge.) . 270 

98. First Position : Movement of Flexion 271 

99. First Position : Occiput in Cavity of Pelvis. (After Hodge.) 273 

100. First Position : Occiput at Outlet of Pelvis. (After Hodge.) 274 

101. First Position : Head Delivered. (After Hodge.) 275 

102. External Rotation of Head in First Position. (After Hodge.) 275 

103. Third Position of Occiput at Brim of Pelvis 276 

104. Fourth Position of Occiput at Pelvic Brim 278 

105. P]xamination during the First Stage of Labor 282 

106. Mode of effecting Relaxation of the Perineum 288 

107. Usual Method of Removing the Placenta by Traction on the Cord .... 291 

108. Illustrating Expression of the Placenta 293 

109. First, or left Sacro-anterior position of the Breech 303 

110. Passage of the Shoulders and partial Rotation of the Thorax 304 

111. Descent of the Plead 304 



xxiv ILLUSTRATIONS. 

FIG. PAGE 

112. Third Position in Face Presentation 313 

113. Rotation forward of Chin 314 

114. Passage of the Head through the External Parts in Face Presentation . . . 315 

115. Illustrating the Position of the Head when Forward Rotation of the Chin 

does not take place 315 

116. Dorso-anterior Presentation of the Arm 323 

117. Dorso-posterior Presentation of the Arm 324 

118. Spontaneous Evolution. (After Chiara.) 329 

119. Dorsal Displacement of the Arm 331 

120. Dorsal Displacement of the Arm in Footling Presentation. (After Barnes.) 331 

121. Prolapse of the Umbilical Cord 332 

122. Postural Treatment of Prolapse of the Cord 334 

123. Braun's Apparatus for Replacing the Cord 336 

124. Labor complicated by Ovarian Tumor 358 

125. Twin Pregnancy, Breech and Head presenting 363 

126. Head Locking, both Children presenting Head first. (After Barnes.) . . . 365 

127. Head Locking, first Child coming Feet first : Impaction of Heads from 

wedging in Brim. (After Barnes.) 366 

128. Labor impeded by Hydrocephalus 371 

129. Adult Pelvis retaining its Infantile Type 378 

130. Scolio-rachitic Pelvis 379 

131. Rickety Pelvis, with backward depression of Symphysis Pubis 380 

132. Flatness of Sacrum, with narrowing of the Pelvic Cavity 381 

133. Pelvis deformed by Spondylolisthesis. (After Kilian.) 381 

134. [ " " " " (After Neugebauer.)] 382 

135. Osteo-malacic Pelvis 385 

136. Extreme degree of Osteo-malacic Deformity 385 

137. Obliquely-contracted Pelvis. (After Duncan.) 386 

138. Kyphotic Pelvis 387 

139. Robert's, or Double Obliquely-contracted Pelvis. (After Duncan.) .... 387 

140. Bony Growth from Sacrum obstructing the Pelvic Cavity 388 

141. Greenhalgh's Pelvimeter 393 

142. Section of Foetal Cranium, showing its Conical Form 396 

143. Showing the greater Breadth of the Bi-parietal Diameter of the Foetal 

Cranium. (After Simpson.) 396 

144. Showing the greater Space for the Bi-parietal Diameter at the side of the 

Pelvis in certain Cases of Deformity. (After Simpson.) 397 

145. Irregular Contraction of the Uterus, with Encystment of the Placenta . . . 418 

146. Illustrating the Dangerous Thinning of the Lower Segment of Uterus, 

owing to non-descent of Head in a case of Intra-uterine Hydrocephalus. 

(After Bandl.) 434 

147. Partial Inversion of the Fundus 443 

148. Illustrating the Commencement of Inversion at the Cervix. (After Duncan.) 446 

149. Barnes's Bag for Dilating the Cervix 453 

150. First Stage of Bi-polar Version. (After Barnes.) 463 

151. Second Stage of Bi-polar Version. ( After Barnes. ) 464 

152. Third Stage of Bi-polar Version. (After Barnes.) 464 

153. Fourth Stage of Bi-polar Version. (After Barnes. ) ... 465 

154. Seizure of the Feet when the Hand is introduced into the Uterus 466 

155. Drawing down of the Feet and Completion of Version 467 

156. Showing the Completion of Version. (After Barnes.) 469 

157. Showing the use of the Right Hand in Abdomino-anterior positions . . . 470 



ILLUSTRATIONS. xxv 

FIG. PAGE 

158. Denman's Short Forceps , 473 

159. Ziegler's Forceps . 473 

160. Simpson's Forceps 474 

161. Tarnier's Forceps 476 

162. Simpson's Axis-Traction Forceps 476 

163. Position of Patient for Forceps Delivery, and Mode of Introducing the 

Lower Blade 480 

164. Introduction of the Upper Blade 481 

165. Forceps in position ; Traction in the Axis of the Brim, downward and 

backward 482 

166. Last Stage of Extraction ; the Handles of the Forceps turned upward 

toward the Mother's Abdomen 483 

167. Hodge Forceps 488 

168. Wallace Forceps 488 

169. Davis Forceps 488 

170. Elliott Forceps 490 

171. SaAvyer Forceps , . . 490 

172. Application of the Forceps at the Inferior Strait 491 

173. Application of the Forceps with the Head at the Superior Strait, the Left 

Blade held in Place by an Assistant 493 

174. Direction of the Forceps as the Head is being Delivered 494 

175. Vectis with Hinged Handle 496 

176. Wilmot's Fillet - . . 497 

177. , 

178. V Various Forms of Perforators 499 

179. J 

18 °- } Crotchets 499 

181. i 

182. Craniotomy Forceps 499 

183. Simpson's Cranioclast 500 

184. Hicks's Cephalotribe '. 501 

185. Perforation of the Skull 505 

186. Foetal Head crushed by Cephalotribe 507 

187. Professor Simpson's Basilyst 508 

188. Straight Craniotomy Forceps 509 

189. Curved Craniotomy Forceps 510 

190. Method of Transfusion by Aveling's Apparatus 541 

191. Schiifer's Canula for Immediate Transfusion 541 

192. Section of a Uterine Sinus from the Placental Site nine weeks after delivery. 

(After Williams.) 551 



193. 
194. 
195. 

196. I 

197. I 



f 609 

(Hit 

ft 1 1 

Temperature Charts ■{ 

I 612 

613 



198.J l(i!4 

199. Hayes's Tube for Intra-uterine Injections 615 

Temperature Charts 616 



200. 
201. 



PLATE I 



Duodenum 




Rectum 



Portio 

Vaginalis 



Os Pubis 



Bladder 



Clitoris- 



SECTION OF A FROZEN BODY IN THE LAST MONTH OF PREGNANCY (AFTER BRAUNE\ ILLUSTRATING Til 

RELATIONS OF THE UTERUS TO THE SURROUNDING PARTS, AND TnE ATTITUDE OF THE 

FOETUS, WHICH IS LYING IN THE SECOND CRANIAL POSITION. 



PLATE II. 



— Coeliac A. 

— Sup.Mesent.A 
— V. Porta} 



Stomach 




Int. Os Uteri 



El add 



Ext. Os Uteri 



Urethra 



Ext. Os Uteri 



Rectui 



Liqnor Amnii 



SECTION OF A FROZEN BOOT AT THE TERMINATION OF THE FIRST STAGE OF LABOR (AFTER DRA1 \ I 
THE BAG OF MEMBRANES IS STILL UNBROKEN, Till! CERVIX IS FULLY DILATED, AND 
THE HEAD (IN THE SECOND POSITION) IS IN THE PELVIC CAVITV. 



THE 



SCIENCE AND PRACTICE 



MIDWIFERY. 



PART I. 



ANATOMY AND PHYSIOLOGY OF THE ORGANS 
CONCERNED IN PARTURITION 



CHAPTER I. 

ANATOMY OF THE PELVIS. 

The pelvis is the bony basin situated between the trunk and the lower 
extremities. To the obstetrician its study is of paramount important e, 
for it not only contains, in the unimpregnated state, all the organs con- 
nected with the function of reproduction, but through its cavity the 
foetus has to pass in the process of parturition. An accurate knowledge, 
therefore, of its anatomical formation may be said to be the very alpha- 
bet of obstetrics, without which no one can practise midwifery, either 
with satisfaction to himself or safety to his patient. 

In a treatise on obstetrics, however, any detailed account of the purely 
descriptive anatomy of the pelvis would be out of place. A knowledge 
of that must be taken for granted, and it is only necessary to refer to 
those points which have a more or less direct bearing on the study of 
its obstetrical relations. 

The pelvis is formed of four bones. On cither side are the ossa inno- 
minata, joined together by the sacrum ; to the inferior extremity of the 
sacrum is attached the coccyx, which is, in fact, its continuation. 

The os innominatum (Fig. 1) is an irregularly shaped bone originally 
formed of three distinct portions, the ilium, the ischium, and the pubes, 
which remain separated from each other up to and beyond the period of 
puberty. They are united at the acetabulum by a Y-shaped cartilagi- 
nous junction, which does not, as a rule, become ossified until about the 
twentieth year. The consequence is that the pelvis, during the period 
of growth, is subject to the action of various mechanical influences to a 

3 S3 



34 ORGANS CONCERNED IN PARTURITION. 

far greater extent than in adult life ; and these, as we shall presently see, 
have an important effect in determining the form of the bones. The 
external surface and borders of the os innominatum are chiefly of obstet- 
ric interest from giving attachment to muscles, many of which have an 
important accessory influence on parturition, such as the muscles form- 
ing the abdominal wall, which are attached to its crest, and those closing 
its outlet and forming the perineum, which are attached to the tuberosity 
of the ischium. On the anterior and posterior extremities of the crest 
of the ilium are two prominences (the anterior and posterior spinous 
processes) which are points from which certain measurements are some- 
times taken. The internal surface of the upper fan-shaped portion of 

Fig. 1. 



Os Innominatum. 

the os innominatum gives attachment to the iliacus muscle, and contrib- 
utes to the support of the abdominal contents ; along with its fellow of 
the opposite side it forms the false pelvis. The false is separated from 
the true pelvis by the ilio-pectineal line, which, with the upper margin 
of the sacrum, forms the brim of the pelvis. This is of especial obstetric 
importance, as it is the first part of the pelvic cavity through which the 
child passes, and that in which osseous deformities are most often met 
with. At one portion of the ilio-pectineal line, corresponding with the 
junction of the ilium and pubes, is situated a prominence which is 
known as the ilio-pectineal eminence. 

Internal Surface. — The internal smooth surface of the innominate 
bone below the linea ilio-pectinea forms the greater portion of the pelvis 
proper. In front, with the corresponding portions of the opposite bone, 
it forms the arch of the pubes, under which the head of the child passes 
in labor. 

Behind this we observe the oval obturator foramen, and below that 
the tuberosity and spine of the ischium, the latter separating the great 
and lesser sciatic notches, and giving attachment to ligaments of import- 
ance. The rough articulating surface posteriorly, by which the junction 
with the sacrum is effected, may be noted, and above this the prominence 



ANATOMY OF THE PELVIS. 



35 




Sacrum and Coccyx. 



to which the powerful ligaments joining the sacrum and os innominatum 
are attached. 

The sacrum (Fig. 2) is a triangular and somewhat spongy bone form- 
ing the continuation of the spinal column and binding together the ossa 
innominata. It is originally composed of 
five separate portions, analogous to the 
vertebra?, which ossify and unite about the 
period of puberty, leaving on its internal 
surface four prominent ridges at the points 
of junction. The upper of these is some- 
times so well marked as to be mistaken, 
on vaginal examination, for the promontory 
of the sacrum itself. 

The base of the sacrum is about \\ 
inches in width, and its sides rapidly ap- 
proximate until they nearly meet at its 
apex, giving the whole bone a triangular 
or wedge* shape. The anterior and pos- 
terior surfaces also approximate in the 
same way, so that the bone is much thicker 
at the base than at the apex. The sacrum, 
in the erect position of the body, is directed 
from above downward and from before 
backward. At its upper edge it is joined, the lumbosacral cartilage 
intervening, with the fifth lumbar vertebra. The point of junction, 
called the promontory of the sacrum, is of great importance, as on its 
undue projection many deformities of the brim of the pelvis depend. 
The anterior surface of the bone is concave, and forms the curve of the 
sacrum — more marked in some cases than in others. There is also more 
or less concavity from side to side. On it we observe four apertures on 
each side, the intervertebral foramina, giving exit to nerves. The pos- 
terior surface is convex, rough and irregular for the attachment of liga- 
ments and muscles, and showing a ridge of vertical prominences corre- 
sponding to the spinous processes of the vertebrae. 

Mechanical Relations of the Sacrum. — The sacrum is generally 
described as forming a keystone to the arch constituted by the pelvic 
bones, and transmitting the weight of the body, in consequence of its 
wedge-like shape, in a direction which tends to thrust it downward and 
backward, as if separating the ossa innominata. Dr. Duncan/ however, 
has shown, from a careful consideration of its mechanical relations, that 
it should rather be regarded as a strong transverse beam, curved on its 
anterior surface, the extremities of which are in contact with the corre- 
sponding articular surfaces of the ossa innominata. The weight of (lie 
body is thus transmitted to the innominate bones, and through them to 
the acetabula and the femora (Fig. 3). There counter-pressure is 
applied, and the result is, as we shall subsequently sec, an important 
modifying influence on the development and shape of the pelvis. 

The coccyx (Fig. 2) is composed of four small separate bones, which 
eventually unite into one, but not until late in life. The uppermost of 

1 Researches in Obstetrics, p. 67. 



36 ORGANS CONCERNED IN PARTURITION. 

these articulates with the apex of the sacrum. On its posterior surface 
are two small cornua, which unite with corresponding points at the tip 
of the sacrum. The bones of the coccyx taper to a point. To it are 
attached various muscles which have the effect of imparting consider- 
able mobility. During labor, also, it yields to the mechanical pressure 
of the presenting part, so as to increase the antero-posterior diameter of 
the pelvic outlet to the extent of an inch or more. 

Ossification of Coccyx. — If, through disease or accident, as sometimes 
happens, the articular cartilages of the coccyx become prematurely ossi- 
fied, the enlargement of the pelvic outlet during labor may be prevented, 
and considerable difficulty may thus arise. This is most apt to happen 
in aged primiparse or in women who have followed sedentary occupations ; 
and not infrequently, under such circumstances, the bone fractures under 
the pressure to which it is subjected by the presenting part. 

Pelvic Articulations. — The pelvic bones are firmly joined together by 
various articulations and ligaments. The latter are arranged so as to 
complete the canal through which the foetus has to pass, and which is 
in great part formed by the bones. On its internal surface, Vhere the 
absence of obstruction is of importance, they are everywhere smooth ; 
while externally, where strength is the desideratum, they are arranged in 
larger masses, so as to unite the bones firmly together. The pelvic 
articulations have been generally described as symphyses or amphi- 
arthrodia — a term which is properly applied to two articulating surfaces 
united by fibrous tissue in such a way as to prevent any sliding motion. 
It is certain, however, that this is not the case with the joints of the 
female pelvis during pregnancy and parturition. Lenoir found that in 
22 females between the ages of 18 and 35 there was a distinct sliding 
motion. Therefore, the pelvic articulations are, strictly speaking, to be 
considered examples of the class of joints termed arthrodia. 

Lumbosacral Joint. — The last lumbar vertebra is united to the sacrum 
by ligamentous union similar to that which joins the vertebrae to each 
other. The intervening fibro-cartilage forms a disk which is thicker in 
front than behind, and this, in connection with a similar peculiarity of 
the fifth lumbar vertebra, tends to increase the sloped position of the 
sacrum and the angle which it forms with the vertebral column. It 
constitutes the most prominent portion of the promontory of the sacrum, 
and is the part on which the finger generally impinges in vaginal exam- 
inations. The anterior common vertebral ligament passes over the 
surface of the joints, and we also find the ligamenta subflava and the 
interspinous ligaments, as in the other vertebrae. The articular pro- 
cesses are joined together by a fibrous capsule, and there is also a peculiar 
ligament, the lumbo-sacral, extending from the transverse process of the 
vertebra on each side, and attaching itself to the sides of the sacrum and 
the .sacro-iliac synchondrosis. 

Ligaments of Coccyx. — The sacrum is joined to the coccyx, and, in 
some cases at least, the separate bones of the coccyx to each other, by 
small cartilaginous disks like that connecting the sacrum with the last 
lumbar vertebra. They are further united by anterior and posterior 
common ligaments, the latter being much the thicker and more marked. 
In the adult female a synovial membrane is found between the sacrum 



ANATOMY OF THE PELVIS. 



37 



and coccyx, and it is supposed that this is formed under the influence 
of the movements of the bones on each other. 

Sacro-iliac Synchondrosis. — The opposing articular surfaces of the 
sacrum and ilium are each covered by cartilages, that of the sacrum 
being the thicker. These are firmly united, but, in the female, accord- 
ing to Mr. Wood, 1 they are always more or less separated by an inter- 
vening synovial membrane. Posterior to these cartilaginous convex 
surfaces there are strong interosseous ligaments passing directly from 
bone to bone, filling up the interspace between them and uniting them 
firmly. There are also accessory ligaments, such as the superior and 
anterior sacro-iliac, which are of secondary consequence. The posterior 
sacro-iliac ligaments, however, are of great obstetric importance. They 
are the very strong attachments which unite the rough surfaces on 
the posterior iliac tuberosities to the posterior and lateral surfaces of the 
sacrum. They pass obliquely downward from the former points, and 
suspend, as it were, the sacrum from them. According to Duncan, the 
sacrum has nothing to prevent its being depressed by the weight of the 
body but these ligaments, and it is mainly through them that the weight 

Fig. 3. 




Section of Pelvis and Heads of Thigh-bones, showing the Suspensory Action of the Sacro-iliac 

Ligaments. (After Wood.) 

of the body is transmitted to the sacro-cotyloid beams and the heads of 
the femora. 

Sacro-sciatic Ligaments. — The sacro-sciatic ligaments are instrumental 
in completing the canal of the pelvis. The greater sacro-sciatic liga- 
ment is attached by a broad base to the posterior-inferior spine of the 
ilium and to the posterior surfaces of the sacrum and coccyx. Its fibres 
unite into a thick cord, cross each other in an X-like manner, and again 

Todd's Cyclopaedia of Anatomy and Physiology, article '" Pelvis," p. 123. 



38 ORGANS CONCERNED IN PARTURITION. 

expand at their insertion into the tuberosity of the ischium. The lesser 
sacro-sciatic ligament is also attached with the former to the back parts 
of the sacrum and coccyx, its fibres passing to their much narrower 
insertion at the spine of the ischium, and converting the sacro-sciatic 
notch into a complete foramen. 

Obturator Membrane.— -The obturator membrane is the fibrous apon- 
eurosis that closes the large obturator foramen. Joulin 1 supposes that, 
along with the sacro-sciatic ligaments, it may, by yielding somewhat to 
the pressure of the foetal head, tend to prevent the contusion to which 
the soft parts would be subjected if they were compressed between two 
entirely osseous surfaces. 

Symphysis Pubis. — The junction of the pubic bones in front is effected 
by means of two oval plates of fibro-cartilage, attached to each articular 
surface by nipple-shaped projections, which fit into corresponding depres- 
sions in the bones. There is a greater separation between the bones in 
front than behind, where the numerous fibres of the cartilaginous plates 
intersect and unite the bones firmly together. At the upper and back 
part of the articulation there is an interspace between the cartilages 
which is lined by a delicate membrane. In pregnancy this space often 
increases in size, so as to extend even to the front of the joint. The 
juncture is further strengthened by four ligaments — the anterior, the 
posterior, the superior, and the subpubic. Of these the last is the 
largest, connecting together the pubic bones and forming the upper 
boundary of the pubic arch. 

Movements of Pelvic Joints. — The close apposition of the bones of the 
pelvis might not unreasonably lead to the supposition that no move- 
ment took place between its component parts ; and this is the opinion 
which is even yet held by many anatomists. It is tolerably certain, 
however, that even in the unimpregnated condition there is a certain 
amount of mobility. Thus, Zaglas has pointed out 2 that in man there 
is a movement in an antero-posterior direction of the sacro-iliac joints 
which has the eifect, in certain positions of the body, of causing the 
sacrum to project downward to the extent of about a line, thus narrow- 
ing the pelvic brim, tilting up the point of the bone, and thereby enlarg- 
ing the outlet of the pelvis. This movement seems habitually brought 
into play in the act of straining during defecation. 

Observations in the Lower Animals. — During pregnancy in some of the 
lower animals there is a very marked movement of the pelvic articula- 
tions, which materially facilitates the process of parturition. This, in 
the case of the guinea-pig and cow, has been especially pointed out by 
Dr. Matthews Duncan. 3 In the former, during labor the pelvic bones 
separate from each other to the extent of an inch or more. In the latter, 
the movements are different, for the symphysis pubis is fixed by bony 
ankylosis, and is immovable ; but the sacro-iliac joints become swollen 
during pregnancy, and extensive movements in an antero-posterior direc- 
tion take place in them which materially enlarge the pelvic canal during 
labor. 

1 Traite d' Accouchements, p. 11. * 

2 Monthly Journal of Med. Science, Sept., 1851. 

3 Researches in Obstetrics, p. 19. 



AS ATOMY OF THE PELVIS. 



39 



Mode in which the Movements are Effected. — It is extremely probable 
that similar movements take place in women, both in the symphysis 
pubis and in the sacro-iliac joints, although to a less marked extent. 
These are particularly well described by Dr. Duncan. They seem to 
consist chiefly in an elevation and depression of the symphysis pubis, 
either by the ilia moving on the sacrum, or by the sacrum itself under- 
going a forward movement on an imaginary transverse axis passing 
through it, thus lessening the pelvic brim to the extent of one or even 
two lines, and increasing, at the same time, the diameter of the outlet by 
tilting up the apex of the sacrum. These movements are only an exag- 
geration of those which Zaglas describes as occurring normally during 
defecation. The instinctive positions which the parturient woman 
assumes find an explanation in these observations. During the first 
stage of labor, when the head is passing through the brim, she sits or 
stands or walks about, and in these erect positions the symphysis pubis 
is depressed and the brim of the pelvis enlarged to its utmost. As the 

Fig. 4. 




Outlet of Pelvis. 



head advances through the cavity of the pelvis, she can no longer 
maintain her erect position, and she lies down and bends her body 
forward, which has the effect of causing a nutatory motion of the sac- 
rum, with corresponding tilting up of its apex afid an enlargement of 
the outlet. 

Alterations in the Pelvic Joints during Pregnancy. — These movements 
during parturition are facilitated by the changes which are known to 
take place in the pelvic articulations during pregnancy. The ligaments 
and cartilages become swollen and softened, and the synovial membranes 
existing between the articulating surfaces become greatly augmented in 
size and distended with fluid. These changes act by forcing the bones 
apart, as the swelling of a sponge placed between them might do after 
it had imbibed moisture. The reality of these alterations receive- a 
clinical illustration from those cases, which are far from uncommon, in 
which these changes are carried to so extreme an extent that the power 
of progression is materially interfered with for a considerable time after 
delivery. 



40 



OBGANS CONCERNED IN PARTURITION. 



Pelvis as a Whole. — On looking at the pelvis as a whole, we are at 
once struck with its division into the true and false pelvis. The latter 
portion (all that is above the brim of the pelvis) is of comparatively lit- 
tle obstetric importance, except in giving attachments to the accessory 
muscles of parturition, and need not be further considered. The brim 
of the pelvis is a heart-shaped opening, bounded by the sacrum behind, 

Fig. 5. 




The Female Pelvis. 



the linea ilio-pectinea on either side, and the symphysis of the pubes in 
front. All below it 'forms the cavity, which is bounded by the hollow 
of the sacrum behind, by the inner surfaces of the innominate bones at 
the sides and in front, and by the posterior surface of the symphysis 
pubis. It is in this part of the pelvis that the changes in direction 



Fig. 6. 




The Male Pelvis. 



which the foetal head undergoes in labor are imparted to it. The lower 
border of this canal, or pelvic outlet (Fig. 4 s ), is lozenge-shaped, is 
bounded by the ischiatic tuberosities on either side, the tip of the coccyx 
behind, and the under surface of the pubic symphysis in front. Pos- 
teriorly to the tuberosities of the ischia the boundaries of the outlet are 
completed by the sacro-sciatic ligaments. 



AXAT03IY OF THE PELVIS. 



41 



Difference in the Two Sexes. — There is a very marked difference between 
the pelvis in the male and the female, and the peculiarities of the latter all 
tend to facilitate the process of parturition. In the female pelvis (Fig. 5) 
all the bones are lighter in structure, and have the points for muscular 
attachments much less developed. The iliac bones are more spread out, 
hence the greater breadth which is observed in the female figure, and the 
peculiar side-to-side movement which all females have in walking. The 
tuberosities of the ischia are lighter in structure and farther apart, and 
the rami of the pubes also converge at a much less acute angle. This 
greater breadth of the pubic arch gives one of the most easily appreciable 
points of contrast between the male and the female pelvis ; the pubic 
arch in the female forms an angle of from 90° to 100°, while in the 
male (Fig. 6) it averages from 70° to 75°. The obturator foramina 
are more triangular in shape. 

The whole cavity of the female pelvis is wider and less funnel-shaped 
than in the male, the symphysis pubis is not so deep, and, as the promon- 
tory of the sacrum does not project so much, the shape of the pelvic 
brim is more oval than heart-shaped. These differences between the 
male and female pelvis are probably due to the presence of the female 



Fig 




Brim of Pelvis, shewing Anteroposterior, Oblique, and Conjugate Diameter?. 



genital organs in the true pelvis, the growth of which increases its 
development in width. In proof of this, Schroeder states that in women 
with congenitally defective internal organs, and in women who have had 
both ovaries removed early in life, the pelvis has always more or less 
of the masculine type. 

Measurements of the Pelvis. — The measurements of the pelvis that 
are of most importance from an obstetric point of view are taken between 
various points directly opposite to each other, and are known as the 
diameters of the pelvis. Those of the true pelvis arc the diameters 
which it is especially important to fix in our memories, and it is cus- 
tomary to describe three in works on obstetrics — the antero-posterior or 
conjugate, the oblique, and the transverse — although of course the meas- 
urements may be taken at any opposing points in the circumference of the 
bones. The anteroposterior (sacro-pubic), at the brim (Fig. 7), is taken 



42 



ORGANS CONCERNED IN PARTURITION. 



Fig 



from the upper part of the posterior surface of the symphysis pubis to 
the centre of the promontory of the sacrum ; in the cavity, from the cen- 
tre of the symphysis pubis to a cor- 
responding point in the body of the 
third piece of the sacrum ; and at 
the outlet (coccy-pubic), from the 
lower border of the symphysis pubis 
to the tip of the coccyx. The oblique, 
at the brim, is taken from the sacro- 
iliac joint on either side to a point 
of the brim corresponding with the 
ilio-pectineal eminence (that starting 
from the right sacro-iliac joint being 
called the right oblique, that from 
the left the left oblique) ; in the 
cavity a similar measurement is made 
at the same level as the conjugate, 
while at the outlet an oblique diame- 
ter is not usually measured. The 
transverse is taken at the brim, from 
a point midway between the sacro- 
iliac joint and the ilio-pectineal emi- 
nence to a corresponding point at the 
opposite side of the brim ; in the cav- 
ity from points in the same plane as 
the conjugate and oblique diameters ; 
and at the outlet from the centre 
of the inner border of one ischial 
tuberosity to that of the other. 
The measurements given by various 
writers differ considerably and vary 
somewhat in different pelves. Tak- 
ing the average of a large number, 
the following may be given as the 
standard measurements of the female 
pelvis : 

Anteroposterior (in.). Oblique (in.)- Transverse (in.). 

Brim , 4.25 4.8 5.2 

Cavity 4.7 5.2 4.75 

Outlet 5.0 4.2 

Differences in Various Parts of Pelvis. — It will be observed that the 
lengths of the corresponding diameters at different places vary greatly ; 
thus, while the transverse is longest at the brim, the oblique is longest 
in the cavity and the antero-posterior at the outlet. It will be subse- 
quently seen that this fact is of great practical importance in studying 
the mechanism of delivery, for the head in its descent through the pelvis 
alters its position in such a way as to adapt itself to the longest diam- 
eter of the pelvis ; thus, as it passes through the cavity it lies in the 
oblique diameter, and then rotates so as to be expelled in the antero- 
posterior diameter of the outlet. 




Transverse Section of Pelvis, showing the 
Diameters. 



ANATOMY OF THE PELVIS. 



43 



Diameters as Altered by Soft Parts. — In thinking of these measure- 
ments of the pelvis it must not be forgotten that they are taken in the 
dried bones, and that they are considerably modified during life by the 
soft parts. This is especially the case at the brim, where the projection 
of the psoas and iliacus muscles lessens the transverse diameter about 
half an inch, while the antero-posterior diameter of the brim and all the 
diameters of the cavity are lessened by a quarter of an inch. The right 
oblique diameter of the brim is, even in the dried pelvis, found to be on 
an average slightly longer than the left, probably on account of the 
increased development of the right side of the pelvis from the greater 
use made of the right leg ; but in addition to this the left oblique diam- 
eter is somewhat lessened during life by the presence of the rectum on 
the left side. The advantage gained by the comparatively frequent 
passage of the head through the pelvis in the right oblique diameter is 
thus explained. 

Other Measurements. — There are one or two other measurements of the 
true pelvis which are sometimes given, but which are of secondary 
importance. One of these, the sacro-cotyloid diameter, is that between 
the promontory of the sacrum and a point immediately above the coty- 

Fig. 9. 




Planes of the Pelvis with Horizon. 



a b. Horizon. c r>. Vertical lino. 

a b i. Angle of inclination of pelvis to horizon, equal to 60°. 

b i c. Angle of inclination of pelvis to spinal column, equal to 150°. 

c i j. Angle of inclination of sacrum to spinal column, equal to 130 . 

e f. Axis of pelvic inlet. l m. Slid plane in the middle line. 

n. Lowest point of mid plane of ischium. 



loid cavity, and averages from 3.4 to 3.5 inches. Another, called by 
Wood the low r er or inclined conjugate diameter, is that between the 
centre of the lower margin of the symphysis pubis and the promontory 



44 ORGANS CONCERNED IN PARTURITION. 

of the sacrum, and averages half an inch more than the antero-posterior 
diameter of the brim. These measurements are chiefly of importance 
in relation to certain pelvic deformities. 

External Measurements. — The external measurements of the pelvis 
are of no real consequence in normal parturition, but they may help us, 
in certain cases, to estimate the existence and amount of deformities. 
Those which are generally given are : Between the anterior-superior 
iliac spines, 10 inches ; between the central points of the crests of the 
ilia, 10^- inches; between the spinous process of the last lumbar vertebra 
and the upper part of the symphysis pubis (external conjugate), 7 inches. 

Planes of the Pelvis. — By the planes of the pelvis are meant imaginary 
levels at any portion of its circumference. If we were to cut out a piece 
of cardboard so as to fit the pelvic cavity, and place it either at the brim 

Fig. 10. 




Axes of the Pelvis. 



a. Axis of superior plane. b. Axis of mid plane. c. Axis of inferior plane. 

d. Axis of canal. e. Horizon. 

or elsewhere, it would represent the pelvic plane at that particular part, 
and it is obvious that we may conceive as many planes as we desire. 
Observation of the angle which the pelvic planes form with the horizon 
shows the great obliquity at which the pelvis is placed in regard to the 
spinal column. Thus the angle abi (Fig. 9) represents the inclination 
to the horizon of the plane of the pelvic brim, I B, and is estimated to 
be about 60°, while the angle which the same plane forms with the ver- 
tebral column is about 150°. The plane of the outlet forms, with the 
coccyx in its usual position, an angle with the horizon of about 11°, but 
which varies greatly with the movements of the tip of coccyx and the 
degree to which it is pushed back during parturition. These figures 
must only be taken as giving an approximate idea of the inclination of 
the pelvis to the spinal column, and it must be remembered that the 
degree of inclination varies considerably in the same female at different 



ANATOMY OF THE PELVIS. 



45 



times, in accordance with the position of the body. During pregnancy 
especially, the obliquity of the brim is lessened by the patient throwing 
herself backward in order to support more easily the weight of the 
gravid uterus. The height of the promontory of the sacrum above the 
upper margin of the symphysis pubis is on an average about 3f inches, 
and a line passing horizontally backward from the latter point would 
impinge on the junction of the second and third coccygeal bones. 

Axes of the Parturient Canal. — By the axis of the pelvis is meant an 
imaginary line which indicates the direction which the foetus takes 
during its expulsion. The axis of the brim (Fig. 10) is a line drawn 
perpendicular to its plane, which would extend from the umbilicus to 
about the apex of the coccyx ; the axis of the outlet of the bony pelvis 
intersects this, and extends from the centre of the promontory of the 
sacrum to midway between the tuberosities of the ischia. The axis of 
the entire pelvic canal is represented by the sum of the axes of an indef- 
inite number of planes at different levels of the pelvic cavity, which 
forms an irregular parabolic line, as represented in the diagram (Fig. 
10, A d). 

Fig 




Representing General Axis of Parturient Canal, including the Uterine Cavity and Soft Parts. 

It must be borne in mind, however, that it is not the axis of the bony 
pelvis alone that is of importance in obstetrics. We must always, in 
considering this subject, remember that the general axis of the parturient 
canal (Fig. 11) also includes that of the uterine cavity above and of the 
soft parts below. These are variable in direction according to circum- 
stances ; and it is only the axis of that portion of the parturient canal 
extending between the plane of the pelvic brini and a plane between the 



46 ORGANS CONCERNED IN PARTURITION. 

lower edge of the pubic symphysis and the base of the coccyx that is 
fixed. The axis of the lower part of the canal will vary according to 
the amount of distension of the perineum during labor ; but when this is 
stretched to its utmost, just before the expulsion of the head, the axis of 
the plane between the edge of the distended perineum and the lower 
border of the symphysis looks nearly directly forward. The axis of 
the uterine cavity generally corresponds with that of the pelvic brim, 
but it may be much altered by abnormal positions of the uterus, such as 
anteversion from laxity of the abdominal walls. The foetus, under such 
circumstances, will not enter the brim in its proper axis, and difficulties 
in the labor arise. A knowledge of the general direction of the par- 
turient canal is of great importance in practical midwifery in guiding us 
to the introduction of the hand or instruments in obstetric operations, 
and in showing us how to obviate difficulties arising from such acci- 
dental deviations of the uterus as have been just alluded to. 

Cavity of the Pelvis. — The arrangements of the bones in the interior 
of the pelvic canal (Fig. 12) are important in relation to the mechanism 

of delivery. A line passing between 
Fig. 12. the spine of the ischium and the ilio- 

pectineal eminence divides the inner sur- 
face of the ischial bone into two smooth 
plane surfaces, which have received the 
name of the planes of the ischium. 
Two other planes are formed by the 
inner surfaces of the pubic bones in 
front and by the upper portion of the 
sacrum behind, both having a direction 
downward and backward. In studying 
the mechanism of delivery, it will be 
seen that many obstetricians attribute 
to these planes, in conjunction with the 
spines of the ischia, a very important 
influence in effecting rotation of the 
side view of Pelvis. foetal head from the oblique to the an- 

tero-posterior diameter of the pelvis. 
Development of the Pelvis. — The peculiarities of the pelvis during 
infancy and childhood are of interest as leading to a knowledge of the 
manner in which the form observed during adult life is impressed upon 
it. The sacrum in the pelvis of the child (Fig. 13) is less developed 
transversely, and is much less deeply curved, than in the adult. The 
pubes is also much shorter from side to side, and the pubic arch is an 
acute angle. The result of this narrowness of both the pubes and 
sacrum is that the transverse diameter of the pelvic brim is shorter 
instead of longer than the antero-posterior. The sides of the pelvis 
have a tendency to parallelism, as well as the antero-posterior walls ; 
and this is stated by Wood to be a peculiar characteristic of the infantile 
pelvis. The iliac bones are not spread out as in adult life, so that the 
centres of the crests of the ilia are not more distant from each other 
than the anterior-superior spines. The cavity of the true pelvis is 
small, and the tuberosities of the ischia are proportionately nearer to 




ANATOMY OF THE PELVIS. 47 

each other than they afterward become ; the pelvic viscera are conse- 
quently crowded up into the abdominal cavity, which is, for this reason, 
much more prominent in children than in adults. The bones are soft 
and semi-cartilaginous until after the period of puberty, and vield 
readily to the mechanical influences to which they are subjected ; and 
the three divisions of the innominate bone remain separate until about 
the twentieth year. 

As the child grows older the transverse development of the sacrum 
increases, and the pelvis begins to assume more and more of the adult 
shape. The mere growth of the bones, however, is not sufficient to 
account for the change in the shape of the pelvis, and it has been well 

Fig. 13. 




Pelvis of a Child. 



shown by Duncan that this is chiefly produced by the pressure to which the 
bones are subjected during early life. The iliac bones are acted upon by 
two principal and opposing forces. One is the weight of the body above, 
which acts vertically upon the sacral extremity of the iliac beam through 
the strong posterior sacro-iliac ligaments, and tends to throw the lower 
or acetabular ends of the sacro-cotyloid beams outward. This outward 
displacement, how T ever, is resisted, partly by the junction between the 
two acetabular ends at the front of the pelvis, but chiefly by the oppos- 
ing force, which is the upward pressure of the lower extremities through 
the femurs. The result of these counteracting forces is that the still soft 
bones bend near their junction with the sacrum, and thus the greater 
transverse development of the pelvic brim characteristic of adult life is 
established. In treating of pelvic deformities it will be seen that the 
same forces applied to diseased and softened bones explain the peculiari- 
ties of form that they assume. 

Pelvis in Different Races. — The researches that have been made on 
the differences of the pelvis in different races prove that these arc not so 
great as might have been expected. Joulin pointed out that in nil 
human pelves the transverse diameter was larger than the antero-pos- 
terior, while the reverse was the case in all the lower animals, even in 
the highest simile. This observation has been more recently confirmed 



48 ORGANS CONCERNED IN PARTURITION 

by Yon Franque, 1 who has made careful measurements of the pelvis in 
various races. In the pelvis of the gorilla, the oval form of the brim, 
resulting from the increased length of the conjugate diameter, is very 
marked. In certain races there is so far a tendency to animality of type 
that the difference between the transverse and conjugate diameters is 
much less than in European women, but is not sufficiently marked to 
enable us to refer any given pelvis to a particular race. Von Franque 
makes the general observation that the size of the pelvis increases from 
south to north, but that the conjugate diameter increases in proportion 
to the transverse in southern races. 

Soft Parts in connection with Pelvis. — In closing the description of the 
pelvis the attention of the student must be directed to the muscular and 
other structures which cover it. It has already been pointed out that 
the measurements of the pelvic diameters are considerably lessened by 
the soft parts, which also influence parturition in other ways. Thus, 
attached to the crests of the ilia are strong muscles which not only sup- 
port the enlarged uterus during pregnancy, but are powerful accessory 
muscles in labor : in the pelvic cavity are the obturator and pyriformis 
muscles lining it on either side ; the pelvic cellular tissue and fasciae ; 
the rectum and bladder; the vessels and nerves, pressure on which 
often gives rise to cramps and pains during pregnancy and labor ; while 
below the outlet of the pelvis is closed and its axis directed forward by 
the numerous muscles forming the floor of the pelvis and perineum. 
The structures closing the pelvis have been accurately described by Dr. 
Berry Hart, 2 who points out that they form a complete diaphragm 
stretching from the pelvis to the sacrum, in which are three " faults " 
or " slits " formed by the orifices of the urethra, vagina, and rectum. 
The first of these is a mere capillary slit, the last is closed by a strong 
muscular sphincter, while the vagina, in a healthy condition, is also a 
mere slit, with its walls in accurate apposition. Hence it follows that 
none of these apertures impairs the structural efficiency of the pelvic 
floor or the support it gives to the structures above it. 



CHAPTER II. 

THE FEMALE GENERATIVE ORGANS. 

Division according to Function. — The reproductive organs in the 
female are conveniently divided, according to their function, into — 1. 
The external or copulative organs, which are chiefly concerned in the 
act of insemination, and are only of secondary importance in parturi- 
tion : they include all the organs situated externally which form the 
vulva ; and the vagina, which is placed internally and forms the canal 

1 Scanzoni's Beitrage, 1867. 

2 The Structural Anatomy of the Female Pelvic Floor. 



THE FEMALE GENERATIVE ORGANS. 



49 



of communication between the uterus and the vulva. 2. The internal 
or formative organs : they include the ovaries, which are the most im- 
portant of all, as being those in which the ovule is formed ; the Fal- 
lopian tubes, through which the ovule is carried to the uterus ; and the 
uterus, in which the impregnated ovule is lodged and developed. 

1. The external organs consist of — 

Mons Veneris. — The mons veneris (Fig. 14,/) is a cushion of adipose 
and fibrous tissue which forms a rounded projection at the upper part of 
the vulva. It is in relation above with the lower part of the hypogas- 
tric region, from which it is often separated by a furrow, and below it is 
continuous with the labia majora on either side. It lies over the sym- 
physis and horizontal rami of the pubes. After puberty it is covered 

Fig. 14. 





External Genitals of Virgin -with Diaphragmatic Hymen. (After Sappe>0 
Labium inajus. b. Labium minus. c. Praeputium clitoridis. d. Glaus clitoridis. 

e. Vestibule just above urethral orifice. /. .Mons veneris. 



with hair. On its integument are found the openings of numerous 
sweat and sebaceous glands. 

Labia Majora. — The labia majora (Fig. 14, a) form two symmetrical 
sides to the longitudinal aperture of the vulva. They have two surfaces 
■ — one external, of ordinary integument, covered with hair, and another 
internal, of smooth mucous membrane, in apposition with the correspond- 



50 ORGANS CONCERNED IN PARTURITION 

ing portion of the opposite labium, and separated from the external surfaee 
by a free convex border. They are thicker in front, where they run into 
the mons veneris, and thinner behind, where they are united, in front of the 
perineum, by a thin fold of integument called the fourchette, which is 
almost invariably ruptured in the first labor. In the virgin the labia 
are closely in apposition and conceal the rest of the generative organs. 
After childbearing they become more or less separated from each other, 
and in the aged they waste and the internal nymphse protrude through 
them. Both their cutaneous and mucous surfaces contain a large num- 
ber of sebaceous glands, opening either directly on the surface or into 
the hair-follicles. In structure the labia are composed of connective 
tissue, containing a varying amount of fat, and parallel with their exter- 
nal surface are placed tolerably close plexuses of elastic tissue, inter- 
spersed with regularly arranged smooth muscular fibres. These fibres 
are described by Broca as forming a membranous sac resembling the 
dartos of the scrotum, to which the labia majora are analogous. Toward 
its upper and narrower end this sac is continuous with the external 
inguinal ring, and in it terminate some of the fibres of the round liga- 
ment. The analogy with the scrotum is further borne out by the occa- 
sional hernial protrusion of the ovary into the labium, corresponding to 
the normal descent of the testis in the male. 

Labia Minora. — The labia minora, or nymphw (Fig. 14, 6), are two 
folds of mucous membrane, commencing below, on either side, about the 
centre of the internal surface of the labium externum ; thev converge as 

' A/ O 

they proceed upward, bifurcating as they approach each other. The 
lower branch of this bifurcation is attached to the clitoris (Fig. 14, c), 
while the upper and larger unites with its fellow of the opposite side, 
and forms a fold round the clitoris known as its prepuce. The nymphse 
are usually entirely concealed by the labia majora, but after childbearing 
and in old age they project somewhat beyond them ; then they lose their 
delicate pink color and soft texture, and become brown, dry, and like 
skin in appearance. This is especially the case in some of the negro 
races, in whom they form long projecting folds called the apron. 

The surfaces of the nymphse are covered with tessellated epithelium, 
and over them are distributed a large number of vascular papilla?, some- 
what enlarged at their extremities, and sebaceous glands, which are 
more numerous on their internal surfaces. The latter secrete an odor- 
ous, cheesy matter, which lubricates the surface of the vulva and pre- 
vents its folds adhering to each other. The nymphse are composed of 
trabecular of connective tissue containing muscular fibres. 

The Clitoris. — The clitoris (Fig. 14, d) is a small erectile tubercle 
situated about half an inch below the anterior commissure of the labia 
majora. It is the analogue of the penis in the male, and is similar to it 
in structure, consisting of two corpora cavernosa, separated from each 
other by a fibrous septum. The crura are covered by the ischiocavern- 
ous muscles, which serve the same purpose as in the male. It has also 
a suspensory ligament. The corpora cavernosa are composed of a vas- 
cular plexus with numerous traversing muscular fibres. The arteries 
are derived from the internal pud ic artery, which gives a branch, the 
cavernous, to each half of the organ ; there is also a dorsal artery dis- 



THE FEMALE GENERATIVE ORGANS. 51 

tributed to the prepuce. According to Gussenbauer, these cavernous 
arteries pour their blood directly into large veins, and a finer venous 
plexus near the surface receives arterial blood from small arterial 
branches. By these arrangements the erection of the organ which takes 
place during sexual excitement is favored. The nervous supply of the 
clitoris is large, being derived from the internal pudic nerve, which sup- 
plies branches to the corpora cavernosa, and terminates in the glands and 
prepuce, where Paccinian corpuscles and terminal bulbs are to be found. 
On this account the clitoris has been supposed by some to be the chief 
seat of voluptuous sensation in the female. 

The Vestibule — The vestibule (Fig. 14, e) is a triangular space, 
bounded at its apex by the clitoris and on either side by the folds of the 
nymphse. It is smooth, and, unlike the rest of the vulva, is destitute 
of sebaceous glands, although there are several groups of muciparous 
glands opening on its surface. At the centre of the base of the triangle, 
which is formed by the upper edge of the opening of the vagina, is a 
prominence, distant about an inch from the clitoris, on which is the ori- 
fice of the urethra. This prominence can be readily made out by the 
finger, and the depression upon it — leading to the urethra — is of import- 
ance as our guide in passing the female catheter. This little operation 
ought to be performed without exposing the patient, and it is done in 
several ways. The easiest is to place the tip of the index finger of the 
left hand (the patient lying on her back) on the apex of the vestibule, 
and slip it gently down until we feel the bulb of the urethra and the 
dimple of its orifice, which is generally readily found. If there is any 
difficulty in finding the orifice, it is well to remember that it is placed 
immediately below the sharp edge of the lower border of the symphy- 
sis pubis, which will guide us to it. The catheter (and a male elastic 
catheter is always the best, especially during labor, when the urethra is 
apt to be stretched) is then passed under the thigh of the patient and 
directed to the orifice of the urethra by the finger of the left hand, which 
is placed upon it. We must be careful that the instrument is really 
passed into the urethra, and not into the vagina. It is advisable to 
have a few feet of elastic tubing attached to the end of the catheter, so 
that the urine can be passed into a vessel under the bed without uncov- 
ering the patient. If the patient be on her side, in the usual obstetric 
position, the operation can be more readily performed by placing the 
tip of the finger in the vagina and feeling its upper edge. The orifice 
of the urethra lies immediately above this, and if the catheter be slipped 
along the palmar surface of the finger, it can generally be inserted with- 
out much trouble. If, however, as is often the case during labor, the 
parts are much swollen, it may be difficult to find the aperture, and it is 
then always better to look for the opening than to hurt the patient by 
long-continued efforts to feel it. 

The Urethra. — The urethra is a canal 1J inches in length, and it i< 
intimately connected with the anterior wall of the vagina, through which 
it may be felt. It is composed of muscular and erectile tissue, and in 
remarkable for its extreme dilatability — a property which is turned to 
practical account in some of the operations for stone in the female 
bladder. 



52 ORGANS CONCERNED IN PARTURITION. 

Orifice of the Vagina. — The orifice of the vagina is situated immedi- 
ately below the bulb of the urethra. In virgins it is a circular opening, 
but in women who have borne children or practised sexual intercourse 
it is, in the undistended state, a fissure, running transversely and at 
right angles to that between the labia. 1 In virgins it is generally more 
or less blocked up by a fold of mucous membrane, containing some 
cellular tissue and muscular fibres, with vessels and nerves, which is 
known as the hymen. This is most often crescentic in shape, with the 
concavity of the crescent looking upward ; sometimes, however, it is cir- 
cular with a central opening, or cribriform ; or it may even be entirely 
imperforate, and this gives rise to the retention of the menstrual secre- 
tion. These varieties of form depend on the peculiar mode of develop- 
ment of the fold of vaginal mucous membrane which blocks up the 
orifice of the vagina in the foetus, and from which the hymen is formed. 
The density of the membrane also varies in different individuals. Most 
usually it is very slight, so as to be ruptured in the first sexual 
approaches, or even by some accidental circumstance, such as stretching 
the limbs, so that its absence cannot be taken as evidence of want of 
chastity. A knowledge of this fact is of considerable importance from 
a medico-legal point of view. Sometimes it is so tough as to prevent 
intercourse altogether, and may require division by the knife or scissors 
before this can be effected ; and at others it rather unfolds than ruptures, 
so that it may exist even after impregnation has been effected, and it has 
been met with intact in women who have habitually led unchaste lives. 
In a few rare cases it has even formed an obstacle to delivery, and has 
required incision during labor. 

Carunculce Myrtiformes. — The carunculce myrtiformes are small fleshy 
tubercles, varying from two to five in number, situated around the orifice 
of the vagina, and which are generally supposed to be the remains 
of the ruptured hymen. Schroeder, however, maintains that they are 
only formed after childbearing in consequence of parts of the hymen 
having been destroyed by the injuries received during the passage of the 
child. 

Vulvo-vaginal Glands. — Near the posterior part of the vaginal orifice, 
and below the superficial perineal fascia, are situated two conglomerate 
glands which are the analogues of Cowper's glands in the male. Each 
of these is about the size and shape of an almond, and is contained in a 
cellular fibrous envelope. Internally they are of a yellowish -white color, 
and are composed of a number of lobules separated from each other by 
prolongations of the external envelope. These give origin to separate 
ducts which unite into a common canal, about half an inch in length, 
which opens in front of the attached edge of the hymen in virgins, and 
in married women at the base of one of the carunculse myrtiformes. 
According to Huguier, the size of the glands varies much in different 
women, and they appear to have some connection with the ovary, as he 
has always found the largest gland to be on the same side as the largest 
ovary. They secrete a glairy, tenacious fluid, which is ejected in jets 
during the sexual orgasm, probably through the spasmodic action of the 
perineal muscles. At other times their secretion serves the purpose of 

1 Hart, op. cit. 



THE FEMALE GENERATIVE ORGANS. 



53 



lubricating the vulva, and thus preserves the sensibility of its mucous 
membrane. 

Fossa Navicularis. — Immediately behind the hymen in the unmarried, 
and between it and the perineum, is a small depression called the fossa 
navicularis, which disappears after childbearing. 

Perineum. — The perineum separates the orifice of the vagina from that 
of the rectum. It is about 1-J inches in breadth, and is of great obstetric 
interest, not only as supporting the internal organs from below, but 
because of its action in labor. It is largely stretched and distended by 
the presenting part of the child, and if unusually tough and unyielding 
may retard delivery, or it may be torn to a greater or less extent, thus 
giving rise to various subsequent troubles. 

Vascular Supply of the Vulva. — The structures described above 
together form the vulva, and they are remarkable for their abundant vas- 

Fig. 15. 




Vascular Supply of Vulva. (After Kobelt.) 

a. Bulb of vestibule, b. Muscular tissue of vagina, c, d, e, f. The clitoris and muscles, g, h, i, Je, 1, m, n. 

Veins of the nymphae and clitoris communicating with the epigastric and obturator veins. 

cular and nervous supply. The former constitutes an erectile tissue, 
similar to that which has already been described in the clitoris, and 
which is especially marked about the bulb of the vestibule (Fig. 15). 
From this point and extending on either side of the vagina there is a 
well-marked plexus of convoluted veins, which, in their distended state, 
are likened by Dr. Arthur Farre to a filled leech. The erection of the 
erectile tissue, as well as that of the clitoris, is brought about under 
excitement, as in the male, by the compression of the efferent veins by 
the contraction of the ischio-cavernous muscles, and by that of a thin 
layer of muscular tissues surrounding the orifice of the vagina and 
described as the constrictor vaginae. 



54 



ORGANS CONCERNED IN PARTURITION. 



The Vagina. — The vagina is the canal which forms the communica- 
tion between the external and internal generative organs, through which 
the semen passes to reach the uterus, the menses flow, and the foetus is 
expelled. Koughly speaking, it lies in the axis of the pelvis, but its 
opening is placed anterior to the axis of the pelvic outlet, so that its 
lower portion is curved forward, so as to lie parallel to the pelvic brim. 
It is narrow below, but dilated above, where the cervix uteri is inserted 
into it, so that it is more or less conoidal in shape. Under ordinary cir- 
cumstances, especially in the virgin, the anterior and posterior walls lie 
in close contact with each other (see Plate I.), and there is, strictly speak- 
ing, no vaginal canal, although they are capable of wide distension, as in 
copulation and during the passage of the foetus. The anterior wall of 
the vagina is shorter than the posterior, the former measuring on an 
average 2|- inches, the latter 3 inches ; but the length of the canal varies 
greatly in different subjects and under certain circumstances. In front 
the vagina is closely connected with the base of the bladder, so that 
when the vagina is prolapsed, as often occurs, it drags the bladder with 
it (Fig. 17) ; behind, it is in relation with the rectum, but less intimately ; 
laterally with the broad ligaments and pelvic fascia ; and superiorly with 
the lower portion of the uterus and folds of peritoneum both before and 
behind. The vagina is composed of mucous, muscular, and cellular 
coats. The mucous lining is thrown into numerous folds. These start 
from longitudinal ridges which exist on both the anterior and posterior 
walls, but most distinctly on the anterior. They are very numerous in 
the young and unmarried, and greatly increase the sensitive surface of 
the vagina (Fig. 16). After childbearing, and in the aged, they become 

Fig. 16. 




Eight Half of Virgin Vagina, with Walls held apart, showing the abundant Transverse Rugae, 
the greater depth of the Vagina above than below, and the Hymenial Segment. (Alter Hart.) 

atrophied, but they never completely disappear, and toward the orifice 
of the vagina, where they exist in greatest abundance, they arc always 
to be met Avith. The whole of the mucous membrane is lined with tes- 
sellated epithelium, and it is covered with a large number of papilla?, 



THE FEMALE GENERATIVE ORGANS. 



00 



either conical or divided, which are highly vascular and project into the 
epithelial layer. Unlike the vulvar mucous membrane, that of the 
vagina seems to be destitute of glands. Beneath the epithelial layer is 
a submucous tissue containing a large number of elastic and some mus- 
cular fibres, derived from the muscular walls of the vagina. These are 
strong and well developed, especially toward the ostium vaginae. They 
consist of two layers — an internal longitudinal and an external circular — 
with oblique decussating fibres connecting the two. Below they are 
attached to the ischio-pubic rami, and above they are continuous with 
the muscular coat of the uterus. The muscular tissue of the vagina 

Fig. 17. 




Longitudinal Section of Body, showing Relations of Generative Organs. 



increases in thickness during pregnancy, but to a much less degree than 
that of the uterus. Its vascular arrangements, like those of the vulva, 
are such as to constitute an erectile tissue. The arteries form an intricate 
network around the tube, and eventually end in a submucous capillary 
plexus from which twigs pass to supply the papillae ; these nun in give 
origin to venous radicles which unite into meshes freely interlacing with 
each other and forming a well-marked venous plexus. 

2. The Internal Organ* of Generation. — The internal organs of gen- 
eration consist of the uterus, the Fallopian tubes, and the ovaries ; and 
in connection with them we have to study the various ligaments and 
folds of peritoneum which serve to maintain the organs in position, 
along with certain accessory structures. Physiologically, the most im- 
portant of all the generative organs are the ovaries, in which the ovules 



56 



ORGANS CONCERNED IN PARTURITION. 



are formed, and which dominate the entire reproductive life of the 
female. The Fallopian tubes, which convey the ovule to the uterus, 
and the uterus itself — whose main function is to receive, nourish, and 
eventually expel the impregnated product of the ovary — may be said to 
be, in fact, accessory to these viscera. Practically, however, as obstet- 
ricians, Ave are chiefly concerned with the uterus, and may conveniently 
commence with its description. 

The Uterus. — The uterus is correctly described as a pyriform organ, 
flattened from before backward, consisting of the body, with its rounded 
fundus, and the cervix, which projects into the upper part of the vaginal 
canal. In the adult female it is deeply situated in the pelvis, being 
placed between the bladder in front and the rectum behind, its fundus 
being below the plane of the pelvic brim (Fig. 18). It only assumes 
this position, however, toward the period of puberty ; and in the foetus 
it is placed much higher, and lies, indeed, entirely within the cavity of 
the abdomen. It is maintained in this position partly by being slung 

Fig. 18. 




Transverse Section of the Body, showing Relations of the Fundus Uteri. 
m. Pubes. a a (in front). Remainder of hypogastric arteries, a a (behind). Spermatic vessels and nerves. 
B. Bladder. L L. Round ligaments. U. Fundus uteri, t, t. Fallopian tubes, o, o. Ovaries, r. Rectum. 
g. Right ureter, resting on the psoas muscle, c. Utero-sacral ligaments, v. Last lumbar vertebra. 

by its ligaments, which we shall subsequently study, and partly by being 
supported from below by the pelvic cellular tissue and the fleshy column 
of the vagina. The result is that the uterus, in the healthy female, is a 
perfectly movable body, altering its position to suit the condition of the 
surrounding viscera, especially the bladder and rectum, which are sub- 
jected to variations of size according to their fulness or emptiness. 
When from any cause — as, for example, some peri-uterine inflammation 
producing adhesions to the surrounding textures — the mobility of the 
organ is interfered with, much distress ensues, and if pregnancy super- 
venes more or less serious consequences may result. Generally speaking, 



THE FEMALE GENERATIVE ORGANS. 57 

the uterus may be said to lie in a line roughly corresponding with the 
axis of the pelvic brim, its fundus being pointed forward, and its cervix 
lying in such a direction that a line drawn from it would impinge on 
the junction between the sacrum and coccyx. According to some 
authorities, the uterus in early life is more curved in the anterior direc- 
tion, and is, in fact, normally in a state of anteflexion. Sappey holds 
that this is not necessarily the case, but that the amount of anterior 
curvature depends on the emptiness or fulness to the bladder, on which 
the uterus, as it were, moulds itself in the unimpregnated state. It is 
believed also that the body of the uterus is very generally twisted some- 
what obliquely, so that its interior surface looks a little toward the right 
side, this probably depending on the presence and frequent distension of 
the rectum in the left side of the pelvis. The anterior surface of the 
uterus is convex, and is covered in three-fourths of its extent by the 
peritoneum, which is intimately adherent to it. Below the reflexion of 
the membrane it is loosely connected by cellular tissue to the bladder, 
so that any downward displacement of the uterus drags the bladder 
along with it. The posterior surface is also convex, but more distinct- 
ly so than the anterior, as may be observed in looking at a transverse 
section of the organ (Fig. 19). It is also covered by peritoneum, the 

Fig. 19. 




Transverse Section ol Uterus. 

reflexion of which on the rectum forms the cavity known as Douglas's 
pouch. The fundus is the upper extremity of the uterus, lying above 
the points of entry by the Fallopian tubes. It is only slightly rounded 
in the virgin, but becomes more decidedly and permanently rounded in 
the woman who has borne children. 

Its Surfaces. — Until the period of puberty the uterus remains small 
and undeveloped (Fig. 20) ; after that time it reaches the adult size, at 
which it remains until menstruation ceases, when it again atrophies. If 
the woman has borne children it always remains larger than in the nul- 
lipara. In the virgin adult the uterus measures 1\ inches from the 
orifice to the fundus, rather more than half being taken up by the 
cervix. Its greatest breadth is opposite the insertion of the Fallopian 
tubes; its greatest thickness, about 11 or 12 lines, opposite the centre 
of its body. Its average weight is about 9 or 10 drachms. Independ- 
ently of pregnancy, the uterus is subject to great alterations of size 
toward the menstrual period, when, on account of the congestion then 
present, it enlarges, sometimes, it is said, considerably. This fact should 
be borne in mind, as this periodical swelling might be taken for an early 
pregnancy. 



58 



ORGANS CONCERNED IN PARTURITION. 



Regional Divisions. — For the purpose of description the uterus is con- 
veniently divided into the fundus, with its rounded upper extremity, 
situated between the insertions of the Fallopian tubes ; the body, which 
is bounded above by the insertions of the Fallopian tubes and below 
by the upper extremity of the cervix, and which is the part chiefly con- 



Fig. 20. 




Uterus and Appendages in an Infant. (After Farre. 



cerned in the reception and growth of the ovum ; and the cervix, which 
projects into the vagina, and dilates during labor to give passage to the 
child. The cervix is conical in shape, measuring 11 to 12 lines trans- 
versely at the base, and 6 or 7 in the antero-posterior direction ; while 
at the apex it measures 7 to 8 transversely, and 5 antero-posteriorly. 
It projects about 4 lines into the canal of the vagina, the remainder 
of the cervix being placed above the reflexion of the vaginal mucous 
membrane. It varies much in form in the virgin and nulliparous 
married woman and in the woman who has borne children ; and the 
differences are of importance in the diagnosis of pregnancy and uterine 
disease. In the virgin it is regularly pyramidal in shape. At its lower 
extremity is the opening of the external os uteri, forming a small trans- 
verse fissure, sometimes difficult to feel, and generally described as giving 
a sensation to the examining finger like the extremity of the cartilage at 
the tip of the nose. It is bounded by two lips, the anterior of which is 
apparently larger on account of the position of the uterus. The surface 
of the cervix and the borders of the os are very smooth and regular. 

Changes after Childbirth. — In women who have borne children these 
parts become considerably altered. The cervix is no longer conical, but 
is irregular in form and shortened. The lips of the os uteri become 
fissured and lobulated, on account of partial lacerations which have 
occurred during labor. The os is larger and more irregular in outline, 
and is sometimes sufficiently patulous to admit the tip of the finger. In 
old age the cervix atrophies, and after the change of life it not uncom- 



THE FEMALE GENERATIVE ORGANS. 



59 



raoiily entirely disappears, so that the orifice of the os uteri is on a level 
with the roof of the vagina. 

Internal Surface of the Uterus. — The internal surface of the uterus 
comprises the cavities of the body and cervix — the former being rather 
less than the latter in length in virgins, but about equal in women who 
have borne children — separated from each other by a constriction form- 
ing the upper boundary of the cervical canal. The cavity of the body 
is triangular in shape, the base of the triangle being formed by a line 
joining the openings of the Fallopian tubes, its apex by the upper orifice 
of the cervix, or internal os, as it is sometimes called. In the virgin 
its boundaries are somewhat convex, projecting inward. After child- 
bearing they become straight or slightly concave. The opposing surfaces 
of the cavity are always in contact in the healthy state, or are only sep- 
arated from each other by a small quantity of mucus. 

Cavity of the Cervix. — The cavity of the cervix is spindle-shaped or 
fusiform, narrower above and below at the internal and external os 
uteri, and somewhat dilated between these two points. It is flattened 




Portion of Interior of Cervix. (Enlarged nine diameters.) (After Tyler Smith and Hassall. 



from before backward, and its opposing surfaces also lie in contact, but 
not so closely as those of the body. On the mucous lining of the 
anterior and posterior surfaces is a prominent perpendicular ridge, with 
a lesser one at each side, from which transverse ridges proceed at more 
or less acute angles. They have received the name of the arbor vitn\ 
According to Guyon, the perpendicular ridges are not exactly opposite, 
so that they fit into each other, and serve more completely to fill up the 
cavity of the cervix, especially toward the internal os (Fig. 21). The 



60 



ORGANS CONCERNED IN PARTURITION. 



Fig. 22. 



4 



*k 



1 



arbor vitse is most distinct in the virgin, and atrophies considerably 
after childbearing. 

The superior extremity of the cervical canal forms a narrow isthmus 
separating it from the cavity of the body, and measuring about fths of 
an inch in diameter. Like the external os, it contracts after the cessa- 
tion of menstruation, and in old age sometimes becomes entirely 
obliterated. 

Structure of the Uterus. — The uterus is composed of three principal 
structures — the peritoneal, muscular, and mucous coats. The perito- 
neum forms an investment to the greater part of the organ, extending 
downward in front to the level of the os internum, and behind to the 

top of the vagina, from which points 
it is reflected upward on the bladder 
and rectum respectively. At the sides 
the peritoneal investment is not so 
extensive, for a little below the level 
of the Fallopian tubes the peritoneal 
folds separate from each other, form- 
ing the broad ligaments (to be after- 
ward described); here it is that the 
vessels and nerves supplying the 
uterus gain access to it. At the 
upper part of the organ the peri- 
toneum is so closely adherent to the muscular tissue that it cannot 
be separated from it ; below, the connection is more loose. The mass 
of the uterine tissue, both in the body and cervix, consists of unstriped 
muscular fibres, firmly united together by nucleated connective tissue 
and elastic fibres. The muscular fibre-cells are large and fusiform, 
with very attenuated extremities, generally containing in their centre 
a distinct nucleus. These cells, as well as their nuclei, become greatly 
enlarged during pregnancy (Fig. 23) ; according to Strieker, this is only 

Fig. 23. 




Muscular Fibres of Unimpregnated Uterus. 

(After Farre.) 

a. Fibres united by connective tissue. 

b. Separate fibres and elementary corpuscles. 




Developed Muscular Fibres from the Gravid Uterus. (After Wagner.) 

the case with the muscular fibres which play an important part in the 
expulsion of the foetus, those of the outermost and innermost layers not 
sharing in the increase of size. 1 In addition to these developed fibres 
there are, especially near the mucous coat, a number of round elementary 
corpuscles, which are believed by Dr. Farre 2 to be the elementary form 
of the muscular fibres, and which he has traced in various intermediate 

1 Comparative Histology, vol. iii. Syd. Soc. Trans., p. 477. 

2 The, Uterus and its Appendages, p. 632. 



THE FEMALE GENERATIVE ORGANS. 61 

states of development. Dr. John Williams 1 believes that a great part 
of the muscular tissue of the uterus, rather more indeed than three- 
fourths of its thickness, is an integral part of the mucous membrane, 
analogous to the muscularis mucosa? of the mucous membrane of the 
alimentary canal. This he describes as being separated from the rest of 
the muscular tissue by a layer of rather loose connective tissue, contain- 
ing numerous vessels. In early foetal life, and in the uteri of some of 
the lower animals, this appearance is very distinct ; in the adult female 
uterus, however, it cannot be readily made put. 

Arrangement of the Muscular Fibres. — On examining the uterine 
tissue in an unimpregnated condition no definite arrangement of its 
muscular fibres can be made out, and the whole seem blended in inex- 
tricable confusion. By observation of their relations when hypertro- 
phied during pregnancy, Helie 2 has shown that they may, speaking 
roughly, be divided into three layers — an external ; a middle, chiefly 
longitudinal ; and an internal, chiefly circular. Into the details of their 
distribution, as described by him, it is needless to enter at length. 
Briefly, however, he describes the external layer as arising posteriorly 
at the junction of the body and cervix, and spreading upward and over 
the fundus. From this are derived the muscular fibres found in the 
broad and round ligaments, and more particularly described by Rouget. 
The middle layer is made up of strong fasciculi, which run upward, but 
decussate and unite with each other in a remarkable manner, so that 
those which are at first superficial become most deeply seated, and vice 
versa. The muscular fasciculi which form this coat curve in a circular 
manner round the large veins, so as to form a species of muscular canal 
through which they run. This arrangement is of peculiar importance, 
as it affords a satisfactory explanation of the mechanism by which 
hemorrhage after delivery is prevented. The internal layer is mainly 
composed of circular rings of muscular fibres, beginning round the 
openings of the Fallopian tubes, and forming wider and wider circles 
which eventually touch and interlace with each other. They surround 
the internal os, to which they form a kind of sphincter. In addition to 
these circular fibres on the internal uterine surface, both anteriorly and 
posteriorly, there is a well-marked triangular layer of longitudinal 
fibres, the base being above and the apex below, which sends muscular 
fasciculi into the mucous membrane. 

Its Mucous Membrane. — The anatomy of the lining membrane of the 
uterus has been the subject of considerable discussion. Its existence has 
been denied by many authorities, most recently by Snow Beck, 3 who 
maintains that it is in no sense a mucous membrane, but only a softened 
portion of true uterine tissue. It is, however, pretty generally admitted 
by the best authorities that it is essentially a mucous membrane, differ- 
ing from others only in being more closely adherent to the subjacent 
structures in consequence of not possessing any definite connective-tissue 
framework. 

It is a pale pink membrane of considerable thickness, most marked at 

1 "On the Structure of the Mucous Membrane of the Uterus," Obsfet. Journ., 1875. 

2 Recherches sur la Disposition des Fibres musculaires de V Uterus, Paris, 1869. 

3 Obst. Trans., vol. xiii. p. 294. 



62 



ORGANS CONCERNED IN PARTURITION 



the centre of the body, where it forms from one-eighth to one-fourth of 
the thickness of the whole uterine walls. At the internal os uteri it 




Lining Membrane of Uterus, showing Network of Capillaries and Orifices of Uterine Glands. 

(After Farre.) 



From the body. 



From orifice of Fallopian tube. 



Fig. 25. 



terminates by a distinct border, which separates it from the mucous 

membrane lining the cervical cavity. 

The Utricular Glands. — On the surface of the mucous membrane may 

be observed a multitude of little openings, about -^-th of a line in width 

(Fig. 24). These are the orifices of the utric- 
ular glands, which are found in immense num- 
bers all over the cavity of the uterus, and very 
closely agglomerated together. They are little 
cul-de-sacs, narrower at their mouths than in 
their length, the blind extremities of which are 
found in the subjacent tissues (Fig. 26). Wil- 
liams describes them as running obliquely to- 
ward the surface at the lower third of the cav- 
ity, perpendicularly at its middle, while toward 
the fundus they are at first perpendicular, and 
then oblique in their course (Fig. 25). By 
others they are described as being often twisted 
and corkscrew-like. One or more may unite to 
form a common orifice, several of which may 
open together in little pits or depressions on 
the surface of the mucous membrane. These 
glands are composed of structureless mem- 
brane lined with epithelium, the precise cha- 
racter of which is doubtful. By some it is de- 
scribed as columnar, by others tessellated, and 
by some again as ciliated. The most generally 
received opinion is that it is columnar, but 
not ciliated ; therein differing from the epithe- 
lium covering the surface of the membrane, 
which is undoubtedly ciliated, the movements 
of the cilia being from within outward. Wil- 
liams, however, has observed cilia in active' 
movement on the columnar epithelium lining 
the glands, and also states that at the deep- 

which pene- 
the columnar epi- 




The Course of the Glands in the 
fully-developed Mucous Mem- 
brane of the Uterus— viz. just 
before the onset of a Menstrual 
Period. (After Williams.) 



trate between the 



seated extremities of the 
muscular fibres for some distance 



glands 



THE FEMALE GENERATIVE ORGANS. 



63 



thelium is replaced by rounded cells. The capillaries of the mucous 
membrane run down between the tubes, forming a lacework on their 
surfaces and round their orifices. No true papillae exist in the mem- 
brane lining the uterine cavity. The mucous membrane of the uterus 
is peculiar in being always in a state of change and alteration, being 
thrown oif at each menstrual period in the form of debris in conse- 
quence of fatty degeneration of its structures, and re-formed afresh 
by proliferation of the cells of the muscular and connective tissues, 
probably from below upward, the new membrane commencing at the 
internal os. Hence its appearance and structure vary considerably 

Fig. 26. 




Vertical Section through the Mucous Membrane of the Human Uterus. (After Turner.) 
e. Columnar epithelium ; the Cilia are uot represented, g g. Utricular glands, ct. ct. Interglandular con- 
nective tissue, v.v. Blood-vessels, m.m. Muscularis mucosas ( 4 5°.) 

according to the time at which it is examined. The subject, however, 
will be more particularly studied in connection with menstruation. 

Mucous Membrane of the Cervix. — The mucous membrane of the cer- 
vix is much thicker and more transparent than that of the body of the 
uterus, from which it also differs in certain structural peculiarities. The 
general arrangements of its folds and surface have already been 
described. The lower half of the membrane lining the cavity of the 
cervix, and the whole of that covering its external or vaginal portion, 
are closely set with a large number of minute filiform or clavate papillae 
(Fig. 27). Their structure is similar to that of the mucous membrane 
itself, of which they seem to be merely elevations. They each contain a 
vascular loop (Fig. 28), and they arc believed by Kilian and Farre to 
be mainly concerned in giving sensibility to this part of the generative 



64 



ORGANS CONCERNED IN PARTURITION. 



tract. All over the interior of the cervix, both on the ridges of the 
mucous membrane and between their folds, are a very large number of 



Fig. 27. 




Villi of Os Uteri stripped of Epithelium. (After Tyler Smith and Hassall.) 

mucous follicles, consisting of a structureless membrane lined with 
cylindrical epithelium and intimately united with connective tissue. 

Fig. 28. 




^HmF^^ 



Villi of Uterus covered with Pavement Epithelium, and containing Looped Vessels. 
(After Tyler Smith and Hassall.) 



THE FEMALE GENERATIVE ORGANS. 65 

They cease at the external orifice of the cervix, and they secrete the 
thick, tenacious, and alkaline mucus which is generally found filling the 
cervical cavity. The transparent follicles, known as the " ouula 
Nabothii" which are sometimes found in considerable numbers in the 
cavity of the cervix, consist of mucous follicles, the mouths of which 
have become obstructed and their canals distended by mucous secretion. 
The lower third of the cervical canal, as well as the exterior of the 
cervix, is covered with pavement epithelium ; while on its upper portion 
is found a columnar and ciliated epithelium similar to that lining the 
uterine cavity. 

Bancll 1 describes the cervical mucous membrance as extending much 
higher in the virgin than in women who have borne children, being 
traceable in the former nearly to the middle of the body of the uterus. 
During the first pregnancy he believes that the upper portion of the 
cervix is taken up into the body of the uterus, its mucous membrane 
never regaining the arrangement peculiar to that of the cervical canal. 

Vessels of the Uterus. — The arteries of the uterus are derived from the 
internal iliac and from the ovarian. They enter the uterus between the 
folds of the broad ligaments, and, penetrating its muscular coat, anas- 
tomose freely with each other and with the corresponding vessels of the 
opposite side. Their walls are thick and well developed, and they are 
remarkable for their very tortuous course, forming spiral curves, espe- 
cially in the upper part of the uterus. They end in minute capillaries 
which form the fine meshes surrounding the glands, and in the cervix 
give oif the loops entering the papilla?. Beneath the uterine mucous 
membrane these capillaries form a plexus, terminating in veins without 
valves, which unite with each other to form the large veins traversing 
the substance of the uterus, known during pregnancy as the uterine 
sinuses, the walls of which are closely adherent to the uterine tissues. 
These veins, freely anastomosing with each other, pass outward to the 
folds of the broad ligaments, where they unite to form, with the ovarian 
and vaginal veins, a large and well-developed venous network, known 
as the pampiniform plexus. 

The Lymphatics of the Uterus. — The lymphatics of the uterus are 
large and well developed, and they have recently, and with much prob- 
ability, been supposed to play an important part in the production of 
certain puerperal diseases. A more minute knowledge than we at pres- 
ent possess of their course and distribution will probably throw much 
light on their influence in this respect. According to the researches of 
Leopold, 2 who has studied their minute anatomy carefully, they originate 
in lymph-spaces between the fine bundles of connective tissue forming 
the basis of the mucous lining of the uterus. Here they are in intimate 
contact with the utricular glands and the ultimate ramifications of the 
uterine blood-vessels. As they pass into the muscular tissue they be- 
come gradually narrowed into lymph-vessels and spaces, which have 
a very complicated arrangement, and which eventually unite together in 
the external muscular layer, especially on the sides of the uterus, to 
form large canals which probably have valves. Immediately under this 
peritoneal covering these lymph-vessels form a large and characteristic 

1 Arch./. Gyn., B. xiv. S. 237. 2 Ibid., Bd. vi. Heft i. 

5 



66 



ORGANS CONCERNED IN PARTURITION. 



network covering the anterior and posterior surfaces of the uterus, and 
present, in various parts of their course, large ampullae. They then 
spread over the Fallopian tubes. The lymphatics of the body of the 
uterus unite with the lumbar glands, those of the cervix with the pel- 
vic glands. 

The Nerves of the Uterus. — The distribution and arrangement of the 
nerves of the uterus have been the subject of much controversy. They 
are derived mainly from the ovarian and hypogastric plexuses, inoscu- 
lating freely with each other between the folds of the broad ligament,, 
from which they enter the muscular tissue of the uterus, generally, but 
not invariably, following the course of the arteries. They are chiefly 
derived from the sympathetic, but, as the hypogastric plexus is connected 
with the sacral nerves, it is probable that some fibres from the cerebro- 
spinal system are distributed to the cervix. It is now generally admit- 
ted that nervous filaments are distributed to the cervix, even as far as 
the external os, although their existence in this situation has been denied 
by Jobert and other writers. The ultimate distribution of the nerves 
is not yet made out. Polle describes a nerve-filament as entering the 
papillae of the cervical mucous membrane along with the capillary loop, 
and Frankenhauser says the nerve-fibres surround the muscles of the 
uterus in the form of plexuses and terminate in the nuclei of the muscle- 
cells. 

Anomalies of the Uterus. — Various abnormal conditions of the uterus 
and vagina are occasionally met with, which it is necessary to mention, 
as they may have an important practical bearing on parturition. The 
most frequent of these is the existence of a double, or partially double, 

Fig. 29. 




Bifid Uterus. (After Farre.) 

uterus (Fig. 29), similar to that found normally in many of the lower 
animals. This abnormality is explained by the development of the 
organ during foetal life. The uterus is formed out of structures existing 
only in early foetal life, known as the Wolffian bodies. Those consist 
of a number of tubes, situated on either side of the vertebral column, 
and opening externally into an excretory duct. Along their external 
border a hollow canal is formed, termed the canal of Midler, which, like 
the excretory ducts, proceeds to the common cloaca of the digestive and 
urinary organs, which then exists. The canal of Midler unites with 



THE FEMALE GENERATIVE ORGANS. 67 

its fellow of the opposite side to form the uterus and Fallopian tubes in 
the female, and subsequently the central partition at their point of junc- 
tion disappears. If, however, the progress of development be in any 
way checked, the central partition may remain. Then we have pro- 
duced either a complete double uterus or the uterus bicornis, which is 
bifid at its upper extremity only ; or a double vagina, each leading to a 
separate uterus. 

Pregnancy in Cases of Bifid Uterus. — If pregnancy occur in any of 
these anomalous uteri — and many such cases are recorded — serious 
troubles may follow. It may happen that one horn of the double uterus 
is not sufficiently large to admit of pregnancy going on to term, and 
rupture may occur. It is supposed that some cases, presumed to be 
tubal gestation, were really thus explicable. Impregnation may also 
occur in the two cornua at different times, leading to superfcetation. It 
is, however, quite possible that impregnation may occur in one horn of 
a bifid uterus, and labor be completed without anything unusual being 
observed. A remarkable case of this sort has been recorded by Dr. Koss 
of Brighton, 1 in which a patient miscarried of twins on July 16, 1870, 
and on October 31, fifteen weeks later, was delivered of a healthy 
child. Careful examination showed the existence of a complete double 
uterus, each side of which had been impregnated. Curiously enough, 
this patient had formerly given birth to six living children at term, 
nothing remarkable having been observed in her labors. It can only 
rarely happen that, under such circumstances, so favorable a result will 
follow, and more or less difficulty and danger may generally be expected. 
Occasionally the vagina only is double, the uterus being single. Dr. 
Matthews Duncan has recorded some cases of this kind 2 in which the 
vaginal septum formed an obstacle to the birth of the child, and required 
division. 

Ligaments of the Uterus. — The various folds of peritoneum which 
invest the uterus serve to maintain it in position, and they are described 
as its ligaments. They are the broad, the vesico-uterine, and sacro- 
uterine ligaments ; the round ligaments are not peritoneal folds like the 
others. 

[Within a few years we have had no less than five reports of cases of 
labor in New York and Philadelphia in which it was claimed that tubal 
fijetal cysts had discharged their contents through the uterus and vagina. 
This is certainly not in accordance with what is usually taught and 
believed in regard to the termination of Fallopian or interstitial preg- 
nancies. The illustration here introduced is in evidence that a uterus 
may be duplex and still bear the outward form of a single organ. ( Jases 
of this type have been distinctly recognized during life by Drs. Baer and 
Drysdale of Philadelphia ; and the patient of the former bore twins, 
whose placentae were discharged separately and at an interval of a 
quarter of an hour. Two of the reports already referred t<» are illus- 
trated by drawings representing a normal uterus and a dilated Fallopian 
tube. How such a cyst is to discharge its contents other than by the usual 
way of bursting into the pelvic cavity I cannot comprehend, particularly 
when we consider that in what is called interstitial pregnancy the thickest 
1 Lancet, August, 1871. 2 Researches in Obstetrics, p. I !■' 



68 



OBGAXS COXCEBXED IN PABTUETTIOX. 



part of the cyst-wall is next to the uterine cavity, and that rupture 
takes place on the remote side. Where the uterus has but one cornu, 
or where one cornu is in a rudimentary state, and pregnancy occurs, we 
may fall into the error of supposing that it is of the Fallopian tube. 
Such a cornu may be emptied per vias natu rales, but the usual terminus 
is by a rupture of the sac. Dr. Sanger of Leipzig calls this form 
" gynatretk" pregnancy, and has collected 21 cases which ended fatally 
in the first six months by rupture, and 3 in which a lithopcedion formed, 
one of which was successfully operated upon by Koeberle.f 1 ] The impreg- 
nated cornu has been removed, successfully in two cases under Salin of 
Stockholm and Sanger, respectively, and unsuccessfully under Litzmann 
of Kiel. Sanger believes it possible to distinguish during life a Fallo- 
pian pregnancy from one of a rudimentary cornu, but this is not the 

Fig. 30. 




Partitioned Uterus. (Kussrnaul.) 

general opinion, as even after death certain anatomical points must be 
relied upon. We must note where the round ligament is given off, it 
being between the cyst and the uterus in a Fallopian pregnancy, and at 
the distal side of an impregnated cornu. It is to be hoped that the five 
cases of New York and Philadelphia under dispute may some day be 
examined by autopsy, and the true character of the pregnancies deter- 
mined. If a Fallopian foetal cyst can discharge itself into the uterus, 
as claimed, it is strange that an impregnated rudimentary cornu almost 
universally fails to do so, but ends fatally by rupture. — El).] 

The Broad Ligament*. — The broad ligaments extend from either side 
of the uterus, where their lamina? are separated from each other, trans- 
versely across to the pelvic wall, and thus divide the cavity of the pelvis 

[ x Trans. Filter national Med. Congress of Copenhagen,} Aug. 16, 1884.] 



THE FEMALE GENERATIVE ORGANS. 69 

into two parts ; the anterior containing the bladder, the posterior the 
rectum. Their upper borders are divided into three subsidiary folds, 
the anterior of which contains the round ligament, the middle the Fal- 
lopian tube, and the posterior the ovary. The arrangement has received 
the name of the ala vespertilionis, from its fancied resemblance to a bat's 
wing. Between the folds of the broad ligaments are found the uterine 
vessels and nerves, and a certain amount of loose cellular tissue con- 




Adult Parovarium, Ovary, and Fallopian Tube. (After Kobelt.) 

tinuous with the pelvic fascise. Here is situated that peculiar structure 
called the organ of Rosenmuller, or the parovarium (Fig. 31), which is the 
remains of the Wolffian body, and corresponds to the epidiclymus in the 
male. This may best be seen in young subjects by holding up the broad 
ligaments and looking through them by transmitted light ; but it exists at 
all ages. It consists of several tubes (eight or ten according to Farre, 
eighteen or twenty according to Bankes r ), which are tortuous in their 
course. They are arranged in a pyramidal form, the base of the pyra- 
mid being toward the Fallopian tube, its apex being lost on the surface 
of the ovary. They are formed of fibrous tissue, and lined with pave- 
ment epithelium. They have no excretory duct or communication with 
either the uterus or ovary, and their function, if they have any, is un- 
known. 

Muscular Fibres between its Folds 1 . — A number of muscular fibres are 
also found in this situation, lying between the meshes of the connective 
tissue. They have been particularly studied by Rouget, who describes 
them as interlacing with each other, and forming an open network con- 
tinuous with the muscular tissues of the uterus (Fig. 32). They are 
divisible into two layers, the anterior of which is continuous with the 
muscular fibres of the anterior surface of the uterus, and goes to form 
part of the round ligament; the posterior arises from the posterior wall 
of the uterus, and proceeds transversely outward to become attached to 
the sacro-iliac synchondrosis. A continuous muscular envelope is thus 
formed, which surrounds the whole of the uterus, Fallopian tubes, and 

1 Bankes, On the Wolffian Bodies. 



70 



ORGANS CONCERNED IN PARTURITION 



ovaries. Its function is not yet thoroughly established. It is supposed 
to have the effect' of retracting the stretched folds of peritoneum after 
delivery, and more especially of bringing the entire generative organs 
into harmonious action during menstruation and the sexual orgasm ; in 
this way explaining, as we shall subsequently see, the mechanism by 
which the fimbriated extremity of the Fallopian tube grasps the ovary 
prior to the rupture of a Graafian follicle. 

The Bound Ligaments. — The round ligaments are essentially muscular 
in structure. They extend from the upper border of the uterus, with 
the fibres of which their muscular fibres are continuous, transversely and 
then obliquely downward, until they reach the inguinal rings, where 
they blend with the cellular tissue. In the first part of their course the 



Fig. 32. 




Posterior View of Muscular and Vascular Arrangements. (After Rouget.) 

Vessels : 1, 2, 3. Vaginal, cervical, and uterine plexuses. 4. Arteries of body of uterus. 5. Arteries sup- 
plying ovarv. Muscular fasciculi: 0.7. Fibres attached to vagina, symphysis pubis, and sacro-iliac joint 
8. Muscular fasciculi from uterus and broad ligaments. <J, 10, 11, 12. Fasciculi attached to ovary and Fal- 
lopian tubes. 

muscular fibres are solely of the unstriped variety, but soon they receive 
striped fibres from the transversalis muscles and the columns of the 
inguinal ring, which surround and cover the unstriped muscular tissue. 
In addition to these structures they contain elastic and connective tissue 
and arterial, venous, and nervous branches; the former from the iliac or 
cremasteric arteries, the latter from the genito-crural nerve. According 
to Mr. Rainey, the principal function of these ligaments is to draw the 



THE FEMALE GENERATIVE ORGANS. 71 

uterus toward the symphysis pubis during sexual intercourse, and thus 
to favor the ascent of the semen. 

The Vesico-uterine Ligaments. — The vesico-uterine ligaments are two 
folds of peritoneum passing in front from the lower part of the body of 
the uterus to the fundus of the bladder. 

The Utero-sacral Ligaments. — The utero-sacral ligaments consist of 
folds of peritoneum of a crescentic form, with their concavities looking 
inward : they start from the lower part of the posterior surface of the 
uterus, and curve backward to be attached to the third and fourth sacral 
vertebra?. Within their folds exist bundles of muscular fibres, continu- 
ous with those of the uterus, as well as connective tissue, vessels, and 
nerves. The experiments of Savage, as well as of other anatomists, show 
that these ligaments have an important influence in preventing downward 
displacement of the womb. 

Alterations during Pregnancy. — During pregnancy all these ligaments 
become greatly stretched and unfolded, rising out of the pelvic cavity 
and accommodating themselves to the increased size of the gravid uterus ; 
and the}' again contract to their natural size, possibly through the agency 
of the muscular fibres contained within them, after delivery has taken 
place. 

The Fallopian Tubes. — The Fallopian tubes, the homologues of the 
vasa deferentia in the male, are structures of great physiological interest. 
They serve the double purpose of conveying the semen to the ovary and 
of carrying the ovule to the uterus. From the latter function they may 
be looked on as the excretory ducts of the ovaries ; but, unlike other 
excretory ducts, they are movable, so that they may apply themselves 
to the part of the ovaries from which the ovule is to come ; and so great 
is their mobility that there is reason to believe that a Fallopian tube 
may even grasp the ovary of the opposite side. Each tube proceeds 
from the upper angle of the uterus at first transversely outward, and 
then downward, backward, and inward, so as to reach the neighborhood 
of the ovary. In the first part of its course it is straight ; afterward it 
becomes flexuous and twisted on itself. It is contained in the upper 
part of the broad ligament, where it may be felt as a hard cord. It 
commences at the uterus by a narrow opening, admitting only the pas- 
sage of a bristle, known as the ostium uterinum. As it passes through the 
muscular walls of the uterus the tube takes a somewhat curved course, 
and opens into the uterine cavity by a dilated aperture. From its 
uterine attachment the tube expands gradually until it terminates in its 
trumpet-shaped extremity; just before its distal end, however, it again 
contracts slightly. The ovarian end of the tube is surrounded by a 
number of remarkable fringe-like processes. These consist of longi- 
tudinal membranous fimbria?, surrounding the aperture of the tube, like 
the tentacles of a polyp, varying considerably in number and size, and 
having their edges cut and subdivided. On their inner surface are found 
both transverse and longitudinal folds of mucous membrane, continuous 
with those lining the tube itself (Fig. 33). One of these fimbriae is 
always larger and more developed than the rest, and is indirectly united 
to the surface of the ovary by a fold of peritoneum proceeding from in 
external surface. . Its under surface i^ grooved so as to form a channel, 



72 



OBGANS CONCERNED IN PARTURITION. 



open below. The function of this fringe-like structure is to grasp the 
ovary during the menstrual nisus ; and the fimbria which is attached to 
the ovary would seem to guide the tentacles to the ovary which they are 
intended to seize. One or more supplementary series of fimbriae some- 
times exist, which have an aperture of communication with the canal of 
the Fallopian tube beyond its ovarian extremity. His has recently 
shown that the fimbriated extremity of the tube, after running over the 



Fig. 33. 




Fallopian Tube laid open. (After Richard.) 
a, b. Uterine portion of tube, c, d. Plicae of mucous membrane, e. Tubo-ovarian ligaments and fringes. 

/. Ovary, g. Bound ligaments. 

upper part of the ovary, turns down along its free border ; so that its 
aperture lies below it, ready to receive the ovule when expelled from the 
Graafian follicle. 1 

Their Structure. — The tubes themselves consist of peritoneal, muscu- 
lar, and mucous coats. The peritoneum surrounds the tube for three- 
fourths of its calibre, and comes into contact with the mucous lining at 
its fimbriated extremity, the only instance in the body where such a 
junction occurs. The muscular coat is principally composed of circular 
fibres, with a few longitudinal fibres interspersed. Its muscular charac- 
ter has been doubted by Robin and Richard, but Farre had no difficulty 
in demonstrating the existence of muscular fibres, both in the human 
female and many of the lower animals. According to Robin, the mus- 
cular tissue of the Fallopian tubes is entirely distinct from that of the 
uterus, from which he describes it as being separated by a distinct cellu- 
lar septum. The mucous lining is thrown into a number of remarkable 
longitudinal folds, each of which contains a dense and vascular fibrous 
septum, with small muscular fibres, and is covered with columnar and 
ciliated epithelium. The apposition of these produces a series of minute 
capillary tubes, along which the ovules are propelled, the action of the 
cilia, which is toward the uterus, apparently favoring their progress 

The Ovaries. — The ovaries are the bodies in which the ovules are 

1 His, Archiv fur Anat. und Phys., 1881. 



THE FEMALE GENERATIVE ORGANS. 



73 



formed, and from which they are expelled, and the changes going on in 
them in connection with the process of ovulation, during the whole 
period between the establishment of puberty and the cessation of men- 
struation, have an enormous influence in the female economy. Xormallv, 
the ovaries are two in number; in some exceptional cases a supple- 
mentary ovary has been discovered ; or they may be entirely absent. 
They are placed in the posterior folds of the broad ligament, usually 
below the brim of the pelvis, behind the Fallopian tubes, the left in 
front of the rectum, the right in front of some coils of the small intes- 
tine. Their situation varies, however, very much under different circum- 
stances, so that they can scarcely be said to have a fixed and normal 
position ; most probably, however, as has been recently shown by His, 1 
they are normally placed close below the brim of the pelvis, with their 
long diameters almost vertical, and immediately above the aperture of 
the distal extremity of the Fallopian tubes. In pregnancy they rise 
into the abdominal cavity with the enlarging; uterus ; and in certain con- 
ditions they are dislocated downward into Douglas's space, where they 
may be felt through the vagina as rounded and very tender bodies. 

Their Connections. — The folds of the broad ligament, between which 
the ovaries are placed, form for them a kind of loose mesentery. Each 
of them is united to the upper angle of the uterus by a special ligament 
called the utero-ovarian. This is a rounded band of organic muscular 
fibres, about an inch in length, continuous with the superficial muscular 
fibres of the posterior wall of the uterus, and attached to the inner 




a. Ovary enlarged under menstrual uisus. b. Ripe follicle projecting on its surface, 
previously-ruptured follicles. 



o, a. Traces of 



extremity of the ovary. It is surrounded by peritoneum, and through 
it the muscular fibres, which form an important integral part in the 
structure of the ovaries, are conveyed to them. The ovary is also 
attached to the fimbriated extremity of the Fallopian tube in the man- 
ner already described. 

The ovary is of an irregular oval shape (Fig. 34), the upper border 
being convex, the lower — through which the vessels and nerves enter — 

1 Op. cit. 



74 ORGANS CONCERNED IN PARTURITION. 

being straight. The anterior surface, like that of the uterus, is less 
convex than the posterior. The outer extremity is more rounded and 
bulbous than the inner, which is somewhat pointed and eventually lost 
in its proper ligament. By these peculiarities it is possible to distinguish 
the left from the right ovary after they have been removed from the 
body. The ovary varies much in size under different circumstances. 
On an average, in adult life, it measures from one to two inches in 
length, three-quarters of an inch in width, and about half an inch in 
thickness. It increases greatly in size during each menstrual period — 
a fact which has been demonstrated in certain cases of ovarian hernia, 
in which the protruded ovary has been seen to swell as menstruation 
commenced ; also during pregnancy, when it is said to be double its 
usual size. After the change of life it atrophies, and becomes rough 
and wrinkled on its surface. Before puberty, the surface of the ovary 
is smooth and polished and of a whitish color. After menstruation 
commences, its surface becomes scarred by the rupture of the Graafian 
follicles (Fig. 34, a a), each of which leaves a little linear or striated 
cicatrix of a brownish color ; and the older the patient the greater is 
the number of these cicatrices. 

Their Structure — The structure of the ovary has been made the 
subject of many important observations. It has an external covering 
of epithelium, originally continuous with the peritoneum, called by 
some the germ-epithelium, in consequence of the ovules being formed 
from it in early foetal life. In the adult it is separated from the peri- 
toneum at the base of the organ by a circular white line, and it consists 
of columnar epithelium, differing only from the epithelium lining the 
Fallopian tube's, with which it is sometimes continuous through the 
attached fimbria uniting the tube and the ovary, in being destitute of 
cilia. Immediately beneath this covering is the dense coat known as 
the tunica albuginea, on account of its whitish color. It consists of 
short connective-tissue fibres, arranged in laminae, among which are 
interspersed fusiform muscular fibres. At the point where the vessels 
and nerves enter the ovary this membrane is raised into a ridge, which 
is continuous with the utero-ovarian ligament, and is called the hilum. 

The tunica albuginea is so intimately blended 
Fig. 35. with the stroma of the ovary as to be insep- 

arable on dissection ; it does not, however, ex- 
ist as a distinct lamina, but is merely the ex- 
ternal part of the proper structure of the ovary, 
in which more dense connective tissue is de- 
veloped than elsewhere. 

The Stroma. — On making a longitudinal sec- 
tion of the ovary (Fig. 35), it will be seen to 
be composed of two parts, the more internal of 
which is of a reddish color from the number 
of vessels that ramify in it, and is called the 

Longitudinal Section of Adult 7 77 i ' i «i -1 j. 

Ovary. (After Pane.) medullary or vascular zone; while the exter- 

nal, of a whitish tint, receives the name of 
the cortical or parenchymatous substance. The former consists of loose 
connective tissue interspersed with elastic, and a considerable number of 




THE FEMALE GENERATIVE ORGANS. 



75 



muscular fibres. According to Rouget l and His, 2 the muscular structure 
forms the greater part of the ovarian stroma, The latter describes it as 
consisting essentially of interwoven muscular fibres, which he terms the 
" fusiform tissue/' and which he believes to be continuous with the muscular 
layers of the ovarian vessels. The former believes that the muscular 
fasciculi accompany the vessels in the form of sheaths, as in erectile 
tissues. Both attribute to the muscular tissues an important influence 
in the expulsion of the ovules and in the rupture of the Graafian fol- 



Fig 




Section through the Cortical Part of the Ovary. 
e. Surface epithelium, s s. Ovarian stroma. 11. Large-sized Graafian follicles. 2 2. Middle-sized; and 
3 3. Small-sized Graafian follicles, o. Ovule within Graafian follicle, v v. Blood-vessels in the stroma. 
(j. Cells of the memhrana granulosa. (After Turner.) 

licles. Waldeyer and other writers, however, do not consider it to be 
so extensively developed as Rouget and His believe. The cortical sub- 
stance is the more important, as that in which the Graafian follicles and 
ovules are formed. It consists of interlaced fibres of connective tissue, 
containing a large number of nuclei. The muscular fibres of the medul- 
lary substance do not seem to penetrate into it in the human female. 
In it are found the Graafian follicles, which exist in enormous numbers 
from the earliest periods of life, and in all stages of development (Fig. 
36.) 

The Graafian Follicles. — According to the researches of Pfliiger, 
Waldeyer, and other German writers, the Graafian follicles are formed 
in early foetal life by cylindrical inflections of the epithelial covering of 
the ovary, which dip into the substance of the gland. These tubular 
filaments anastomose with each other, and in them are formed the 
ovules, which are originally the epithelial cells lining the tubes. Por- 
tions become shut off from the rest of the filaments and form the 
Graafian follicles. The ovules, on this view, are highly-developed 
epithelial cells, originally derived from the surface of the ovary, and 
1 Journal de Physiol, i. p. 737. 2 Schultze's Arch.f. Mikroscop. Anat., 1865. 



76 ORGANS CONCERNED IN PARTURITION. 

not developed in its stroma. These tubular filaments disappear shortly 
after birth, but they have recently been detected by Slavyansky * in the 
ovaries of a woman thirty years of age. These observations have been 
modified by Dr. Foulis. 2 He recognizes the origin of the ovules from 
the germ-epithelium covering the surface of the ovary, which is itself 
derived from the Wolffian body. He believes all the ovules to be 
formed from the germ-epithelium corpuscles, which become imbedded 
in the stroma of the ovary, by the outgrowth of processes of vascular 
connective tissue, fresh germ-epithelial corpuscles being constantly pro- 
duced on the surface of the organ up to the age of two and a half years, 
to take the place of those already imbedded in its stroma. He believes 
the Graafian follicles to be formed by the growth of delicate processes 
of connective tissue between and around the ovules, but not from 
tubular inflections of the epithelium covering the gland, as described 
by Waldeyer (Fig. 37). This view is supported by the researches of 
Balfour, 3 who arrives at the conclusion that the whole egg-containing 

Fig. 37. 




Vertical Section through the Ovary of the Human Foetus. 
g g. Germ-epithelium, with o o. Developing ovules in it. s s. Ovarian stroma, containing c c c. Fusiform 
connective-tissue corpuscles, v v. Capillary hlood-vessels. In the centre of the figure an involution of 
the germ-epithelium is shown ; and at the left lower side a primordial ovule, with the connective-tissue 
corpuscles ranging themselves round it. (After Foulis.) 

part of the ovary is really the thickened germinal epithelium, broken 
up into a kind of mesh work by growths of vascular stroma. According 
to this theory, Pfluger's tubular filaments are merely trabecule of 
germinal epithelium, modified cells of which become developed into 
ovules. 

The greater portion of the Graafian follicles are only visible with the 
high powers of the microscope, but those which are approaching matur- 
ity are distinctly to be seen by the naked eye. The quantity of these 
follicles is immense. Foulis estimates that at birth each human ovary 
contains not less than 30,000. No fresh follicles appear to be formed 
after birth, and as development goes on some only grow, and, by pres- 

1 Annates de Gynic, Feb., 1871. 

2 Proceedings of the Royal Soc. of Edinb., April, 1875, and Journ. of Anat. and Phys., 
vol. xiii., 1879. 

8 F. M. Balfour, "Structure and Development of Vertebrate Ovary," Quarterly 
Journal of Microscopical Science, vol. xviii., 1878. 



THE FEMALE GENERATIVE ORGANS. 



77 



sure on the others, destroy them. Of those that grow, of course only 
a few ever reach maturity ; they are scattered through the substance of 
the ovarv, some developing in the stroma, others on the surface of the 
oro-an, where they eventually burst, and are discharged into the Fallo- 
pian tube. 

Structure of the Graafian Follicle. — A ripe Graafian follicle has an 
external investing membrane (Fig. 38), which is generally described as 

Fig. 38. 




Diagrammatic Section of Graafian Follicle. 
1. Ovum. 2. Membrana granulosa. 3. External membrane of Graafian follicle. 4. Its vessels. 5. Ova- 
rian stroma. 6. Cavity of Graafian follicle. 7. External covering of ovary. 

consisting of two distinct layers — the external, or tunica fibrosa, highly 
vascular, and formed of connective tissue; the internal, or tunica pro- 
pria, composed of young connective tissue, containing a large number 
of fusiform or stellate cells and numerous oil-globules. These layers, 
however, appear to be essentially formed of condensed ovarian stroma. 
"Within this capsule is the epithelial lining called the membrana granu- 
losa, consisting of stratified columnar epithelial cells, which, according 
to Foulis, are originally formed from the nuclei of the fibro-nuclear tis- 
sue of the stroma of the ovary. At one part of the circumference of the 
ovisac is situated the ovule, around which the epithelial cells are con- 
gregated in greater quantity, constituting the projection known as the 
discus proligerus. The remainder of the cavity of the follicle is filled 
with a small quantity of transparent fluid, the liquor folliculi, traversed 
by three or four minute bands, the retinacula of Barry, which are 
attached to the opposite walls of the follicular cavity, and apparently 
serve the purpose of suspending the ovule and maintaining it in a proper 
position. In many young follicles this cavity does not at first exist, the 
follicle being entirely filled by the ovule. According to Waldeyer, the 
liquor folliculi is formed by the disintegration of the epithelial cells, 
the fluid thus produced collecting, and distending the interior of the 
follicle. 

The Ovule. — The ovule is attached to some part of the internal sur- 
face of the Graafian follicle. It is a rounded vesicle about yy^th of an 
inch in diameter, and is surrounded by a layer of columnar cell-, dis- 
tinct from those of the discus proligerus, in which it lies. It i- invested 
by a transparent elastic membrane, the zona pellueida, or vitelline mem- 



78 



ORGANS CONCERNED IN PARTURITION. 



brane. In most of the lower animals the zona pellucida is perforated 
by numerous very minute pores, only visible under the highest powers 
of the microscope ; in others there is a distinct aperture of a larger size, 
the micropyle, allowing the passage of the spermatozoa into the interior 
of the ovule. It is possible that similar apertures may exist in the 
human ovule, but they have not been demonstrated. Within the zona 
pellucida some embryologists describe a second fine membrane, the exist- 
ence of which has been denied by Bischoff. The cavity of the ovule is 
filled with a viscid yellow fluid, the yelk, containing numerous granules. 
It entirely fills the cavity, to the walls of which it is non-adherent. In 
the centre of the yelk in young, and at some portion of its periphery in 
mature ovules, is situated the germinal vesicle, which is a clear circular 
vesicle, refracting light strongly, and about g^th of a line in diameter. 
It contains a few granules, and a nucleolus, or germinal spot, which is 
sometimes double. 

From within outward, therefore, Ave find — 

1. The germinal spot ; round this 

2. The germinal vesicle, contained in 

3. The yelk, which is surrounded by the 

4. Zona pellucida, with its layers of columnar epithelial cells. 
These constitute the ovule. 

The ovule is contained in — 

The Graafian follicle, and lies in that part of its epithelial lining 
called the — 

Discus proligerus, the rest of the follicle being occupied by the liquor 
folliculi. Round these we have the epithelial lining or membrana 
granulosa, and the external coat, consisting of the tunica propria and 
the tunica fibrosa. 

The Vessels and Nerves of the Ovary. — The vascular supply of the 
ovary is complex. The arteries enter at the hilum, penetrating the 
stroma in a spiral curve, and are ultimately distributed in a rich capil- 

Fig. 39. 




Bulb of Ovary, 
r. Uterus, o. Ovary and utevo-ovarian ligament, r. Fallopian tube. 1. Utero-ovarian vein. _'. Pampini- 
form ovarian plexus. :s. Commencement of spermatic vein. 

lary plexus to the follicles. The large veins unite freely with each 
other, and form a vascular and erectile plexus, continuous with that sur- 
rounding the uterus, called the bulb of the ovary (Fig. 39). Lymphat- 
ics and nerves exist, but their mode of termination is unknown. 



THE FEMALE GENERATIVE ORGANS. 79 

The Mammary Glands. — To complete the consideration of the gener- 
ative organs of the female we must study the mammary glands, which 
secrete the fluid destined to nourish the child. In the human subject 
they are two in number, and instead of being placed upon the abdomen, 
as in most animals, they are situated on either side of the sternum, over 
the pectorales majora muscles, and extend from the third to the sixth 
rib. This position of the glands is obviously intended to suit the erect 
position of the female in suckling. They are convex anteriorly, and 
flattened posteriorly where they rest on the muscles. They vary greatly 
in size in different subjects, chiefly in proportion to the amount of adi- 
pose tissue they contain. In man, and in girls previous to puberty, 
they are rudimentary in structure, while in pregnant women they 
increase greatly in size, the true glandular structures becoming much 
hypertrophied. Anomalies in shape and position are sometimes 
observed. Supplementary mammae, one or more in number, situated on 
the upper portion of the mammae, are sometimes met with, identical in 
structure with the normally situated glands ; or, more commonly, an 
extra nipple is observed by the side of the normal one. In some races, 
especially the African, the mammae are so enormously developed that 
the mother is able to suckle her child over her shoulder. 

Their Structure. — The skin covering the gland is soft and supple, 
and during pregnancy often becomes covered with fine white lines, while 

Fig. 40. 




1. Galactophorous ducts. 2. Lobuli of the mammary gland. 

large blue veins may be observed coursing over. Underneath it is a 
quantity of connective tissue, containing a considerable amount of fat, 
which extends beneath the true glandular structure. This is composed 
of from fifteen to twenty lobes, each of which is formed of a number of 
lobules. The lobules are produced by the aggregation of the terminal 
acini in which the milk is formed. The acini are minute culs-de-sac 
opening into little ducts, which unite with each other until they form a 
large duct for each lobule ; the ducts of each lobule unite with each other 
until they end in a still larger duct common to each of the fifteen or 
twenty lobes into which the gland is divided, and eventually open on 
the surface of the nipple. These terminal canals are known as the 
galactophorom ducts (Fig. 40). They become widely dilated as they 
approach the nipple, so as to form reservoirs in which milk is stored 
until it is required, but when they actually enter the nipple they again 



80 ORGANS CONCERNED IN PARTURITION. 

contract. Sometimes they give off lateral branches, but, according to 
Sappey, they do not anastomose with each other, as some anatomists 
have described. These excretory ducts are composed of connective tis- 
sue, with numerous elastic fibres, on their external surface. Sappey 
and Robin describe a layer of muscular fibres, chiefly developed near their 
terminal extremities. They are lined with columnar epithelium, con- 
tinuous with that in the acini ; and it is by the distension of its cells with 
fatty matter, and their subsequent bursting, that the milk is formed. 

The Nipple. — The nipple is the conical projection at the summit of 
the mamma, and it varies in size in different women. Not very unfre- 
quently, from the continuous pressure to which it has been subjected by 
the dress, it is so depressed below the surface of the skin as to prevent 
lactation. It is generally larger in married than in single women, and 
increases in size during pregnancy. Its surface is covered with numerous 
papilla?, giving it a rugous aspect, and at their bases the orifices of the 
lactiferous ducts open. Here are also the openings of numerous sebaceous 
follicles, which secrete an unctuous material supposed to protect and 
soften the integument during lactation. Beneath the skin are muscular 
fibres, mixed with connective and elastic tissues, vessels, nerves, and 
lymphatics. When the nipple is irritated it contracts and hardens, and 
by some this is attributed to its erectile properties. The vascularity, 
however, is not great, and it contains no true erectile tissue ; the harden- 
ing is, therefore, due to muscular contraction. Surrounding the nipple 
is the areola, of a pink color in virgins, becoming dark from the develop- 
ment of pigment-cells during pregnancy, and always remaining some- 
what dark after chiklbearing. On its surface are a number of prominent 
tubercles, sixteen to twenty in number, which also become largely 
developed during gestation. They are supposed by some to secrete milk, 
and to open into the lactiferous tubes ; most probably they are composed 
of sebaceous glands only. Beneath the areola is a circular band of mus- 
cular fibres, the object of which is to compress the lactiferous tubes 
which run through it, and thus to favor the expulsion of their contents. 
The mammae receive their blood from the internal mammary and inter- 
costal arteries, and they are richly supplied with lymphatic vessels, which 
open into the axillary glands. The nerves are derived from the inter- 
costal and thoracic branches of the brachial plexus. 

The secretion of milk in women who are nursing is accompanied by 
a peculiar sensation, as if milk were rushing into the breast, called the 
" draught," which is excited by the efforts of the child to suck and by 
various other causes. The sympathetic relations between the mammae 
and the uterus are very well marked, as is shoAvn in the unimpregnated 
state by the fact of the frequent occurrence of sympathetic pains in the 
breast in connection with various uterine diseases, and after delivery by 
the well-known fact that suction produces reflex contraction of the 
uterus, and even severe after-pains. 



Plate in. 





Fig 1. 



Artce-vitPy ruptured and Bfoody Sraafian 
fofncfe-, iust developing ivi bo a Corpus tul-e-uv 



Fi§. 2. 

Corpus Eul'&um ten days aftt-r menshruahov 





*a£ 



Fig. 3, 

<y)e$oviev-cited Sraafiart FoPPuvLe 
wpuew ftas ne,o«r vupfured, 



Fig 4. 

Corpus" Pu tew w of iiSVegnanaj 



ILLUSTRATIONS OF THE CORPUS LUTEUM, (AFTER DALTON.) 



H ~, 



OVULATION AND MENSTRUATION, 81 



CHAPTER III. 
OVULATION AND MENSTRUATION. 

Functions of the Ovary. — The main function of the ovary is to supply 
the female generative element, and to expel it, when ready for impregna- 
tion, into the Fallopian tube, along which it passes into the uterus. 
This process takes place spontaneously in all viviparous animals, and 
without the assistance of the male. In the lower animals this periodical 
discharge receives the name of the oestrum or rut, at which time only 
the female is capable of impregnation and admits the approach of the 
male. In the human female the periodical discharge of the ovule, in all 
probability, takes place in connection with menstruation, which may 
therefore be considered to be the analogue of the rut in animals. Between 
each menstrual period Graafian follicles undergo changes which prepare 
them for rupture and the discharge of their contained ovules. After 
rupture certain changes occur which have for their object the healing of 
the rent in the ovarian tissue through which the ovule has escaped, and 
the filling up of the cavity in which it was contained. This results in 
the formation of a peculiar body in the substance of the ovary, called 
the corpus luteum, which is essentially modified should pregnancy occur, 
and is of great interest and importance. During the whole of the child- 
bearing epoch the periodical maturation and rupture of the Graafian fol- 
licles are going on. If impregnation does not take place, the ovules are 
discharged and lost ; if it does, ovulation is stopped, as a general rule, 
during gestation and lactation. 

Theory of Menstruation. — This, broadly speaking, is an outline of the 
modern theory of menstruation, which was first broached in the year 1821 
by Dr. Power, and subsequently elaborated by Negrier, Bischoff, Racibor- 
ski, and many other writers. Although the sequence of events here indi- 
cated may be taken to be the rule, it must be remembered that it is one sub- 
ject to many exceptions, for undoubtedly ovulation may occur without its 
outward manifestation, menstruation, as in cases in which impregnation 
takes place during lactation or before menstruation has been established, 
of which many examples are recorded. These exceptions have led some 
modern writers to deny the ovular theory of menstruation, and their 
views will require subsequent consideration. 

In order to understand the subject properly it will be necessary to 
study the sequence of events in detail. 

Changes in the Graafian Follicle. — The changes in the Graafian follicle 
which are associated with the discharge of the ovules comprise — 1. 
Maturation. As the period of puberty approaches, a certain number of 
the Graafian follicles, fifteen to twenty in number, increase in size, and 
come near the surface of the ovary. Amongst these one becomes especi- 
ally developed, preparatory to rupture, and upon it, for the time being, 

6 



82 ORGANS CONCERNED IN PARTURITION. 

all the vital energy of the ovary seems to be concentrated. A similar 
change in one, sometimes in more than one, follicle takes place period- 
ically during the whole of the childbearing epoch, in connection with 
each menstrual period, and an examination of the ovary will show 
several follicles in different stages of development. The maturing folli- 
cle becomes gradually larger, until it forms a projection on the surface 
of the ovary, from five to seven lines in breadth, but sometimes even as 
large as a nut (Fig. 34). This growth is due to the distension of the 
follicle by the increase of its contained fluid, which causes it so to press 
upon the ovarian structures covering it that they become thinned, sep- 
arated from each other, and partially absorbed, until they eventually 
readily lacerate. The follicle also becomes greatly congested, the capil- 
laries coursing over it become increased in size and loaded with blood, 
and, being seen through the attenuated ovarian tissue, give it, when 
mature, a bright-red color. At this time some of these distended capil- 
laries in its inner coat lacerate, and a certain quantity of blood escapes 
into its cavity. This escape of blood takes place before rupture, and 
seems to have for its principal object the increase of the tension of the 
follicle, of which it has been termed the menstruation. Pouchet was of 
opinion that the blood collects behind the ovule, and carries it up to the 
surface of the follicle. 2. Escape of the Ovule. By these means the fol- 
licle is more and more distended, until at last it ruptures (Plate III. 
Fig. 1), either spontaneously or, it may be, under the stimulus of sexual 
excitement. Whether the laceration takes place during, before, or after 
the menstrual discharge is not yet positively known ; from the results 
of post-mortem examination in a number of women who died shortly 
before or after the period, Williams believes that the ovules are expelled 
before the monthly flow commences. 1 In order that the ovule may 
escape, the laceration must, of course, involve not only the coats of the 
Graafian follicles, but also the superincumbent structures. 

Laceration seems to be aided by the growth of the internal layer of 
the follicle, which increases in thickness before rupture, and assumes a 
characteristic yellow color from the number of oil-globules it then con- 
tains. It is also greatly facilitated, if it be not actually produced, by 
the turgescence of the ovary at each menstrual period, and by the con- 
traction of the muscular fibres in the ovarian stroma. As soon as the 
rent in the follicular walls is produced, the ovule is discharged, sur- 
rounded by some of the cells of the membrana granulosa, and is received 
into the fimbriated extremity of the Fallopian tube, which grasps the 
ovary over the site of the rupture. By the vibratile cilia of its epithe- 
lial lining it is then conducted into the canal of the tube, along which 
it is propelled, partly by ciliary action and partly by muscular contrac- 
tion in the walls of the tube. 

Obliteration of the Graafian Follicle. — After the ovule lias escaped, 
certain characteristic changes occur in the empty Graafian follicle, which 
have for their object its cicatrization and obliteration. There are great 
differences in the changes which occur when impregnation has followed 
the escape of the ovule, and they are then so remarkable that they have 
been considered certain signs of pregnancy. They are, however, differ- 

1 Proceedings of tfie Royal Society, 1875. 



OVULATION AND MENSTRUATION. 



83 



ences of degree rather than of kind. It will be well, however, to discuss 
,them separately. 

Changes undergone by the Follicle when Impregnation does not Occur. — 
As soon as the ovule is discharged, the edges of the rent through which 
it has escaped become agglutinated by exudation, and the follicle shrinks, 
as is generally believed, by the inherent elasticity of its internal coat, 
but according to Robin, who denies the existence of this coat, from 
compression by the muscular fibres of the ovarian stroma. In pro- 
portion to the contraction that takes place, the inner layer of the fol- 
licle, the cells of which have become greatly hypertrophied and loaded 
with fat-granules previous to rupture, is thrown into numerous folds 
(Plate III. Fig. 2). The greater the amount of contraction the deeper 
these folds become, giving to a section of the follicle an appearance 
similar to that of the convolutions of the 
brain (Fig. 41). These folds in the human 
subject are generally of a bright-yellow 
color, but in some of the mammalia they 
are of a deep red. The tint was formerly 
ascribed by Raciborski to absorption of the 
coloring matter of the blood-clot contained 
in the follicular cavity — a theory he has 
more recently abandoned in favor of the 
view maintained by Coste that it is due to 
the inherent color of the cells of the lining 
membrane of the follicle, which, though 
not well marked in a single cell, becomes 
very apparent en masse. The existence of 
a contained blood-clot is also denied by the Sec tion of 
latter physiologist, except as an unusual 
pathological condition; and he describes 
the cavity as containing a gelatinous and plastic fluid, which becomes 
absorbed as contraction advances. The more recent researches of Dal- 
ton, 1 however, show the existence of a central blood-clot in the cavity 
of the follicle, and he considers its occasional absence to be connected 
with disturbance or cessation of the menstrual function. The folds into 
which the membrane has been thrown continue to increase in size, from 
the proliferation of their cells, until they unite and become adherent, 
and eventually fill the follicular cavity. By the time that another 
Graafian follicle is matured and ready for rupture the diminution has 
advanced considerably, and the empty ovisac is reduced to a very small 
size. The cavity is now nearly obliterated, the yellow color of the con- 
volutions is altered into a whitish tint, and on section the corpus luteum 
has the appearance of a compact white stellate cicatrix, which generally 
disappears in less than forty days from the period of rupture. The tis- 
sue of the ovary at the site of laceration also shrinks, and this, aided by 
the contraction of the follicle, gives rise to one of those permanent pits 
or depressions which mark the surface of the adult ovary. Slavyansky 2 
has shown that only a few of the immense number of Graafian follicles 

1 "Report on the Corpus Luteum," American Gyncec. Trans., vol. ii., 1878. 

2 Archiv. de Phys., March, 1874. 




Ovary, showing Corpus 
Luteum three weeks after Menstru- 
ation. (After Dalton.) 



84 



ORGANS CONCERNED IN PARTURITION. 



undergo these alterations. The greater proportion of them seem never 
to discharge their ovules, but, after increasing in size, undergo retro- 
gressive changes exactly similar in their nature, but to a much less 
extent, to those which result in the formation of a corpus luteum. The 
sites of these may afterward be seen as minute striae in the substance of 
the ovary. 

Changes undergone by the Follicle when Impregnation has taken place. 
— Should pregnancy occur, all the changes above described take place ; 
but, inasmuch as the ovary partakes of the stimulus to which all the 
generative organs are then subjected, they are much more marked and 
apparent (Plate III. Pig. 4). Instead of contracting and disappearing 
in a few weeks, the corpus luteum continues to grow until the third or 
fourth month of pregnancy ; the folds of the inner layer of the ovisac 
become large and fleshy and permeated by numerous capillaries, and 
ultimately become so firmly united that the margins of the convolutions 
thin and disappear, leaving only a firm fleshy yellow mass, averaging 
from 1 to 1-|- inches in thickness, which surrounds a central cavity, often 
containing a whitish fibrillated structure, believed to be the remains of 
a central blood-clot. This was erroneously supposed by Montgomery to 
be the inner layer of the follicle itself, and he conceived the yellow sub- 
stance to be a new formation between it and the external layer, while 
Robert Lee thought it was placed external to both the external and 
internal layers. 

Between the third and fourth months of pregnancy, when the corpus 
luteum has attained its maximum of development (Fig. 42), it forms a 
firm projection on the surface of the ovary, averaging about 1 inch in 



Fig. 42. 



Fig. 43. 





Corpus Luteum of the Fourth Month of 
Pregnancy. (After Dalton.) 



Corpus Luteum of Pregnancy 
at Term. (After Dalton.) 



length and rather more than \ an inch in breadth. After this it com- 
mences to atrophy (Fig. 43), the fat-cells become absorbed, and the 
capillaries disappear. Cicatrization is not complete until from one to 
two months after delivery. 

Its Value as a Sign of Pregnancy. — On account of the marked appear- 
ance of the corpus luteum it was formerly considered to be an infallible 



OVULATIOX AND MENSTRUATION. 85 

sign of pregnancy ; and it was distinguished from the corpus luteum of 
the non-pregnant state by being called a " true " as opposed to a " false " 
corpus luteum. From what has been said it will be obvious that this 
designation is essentially wrong, as the difference is one of degree only. 
Dalton l applies the term " false corpus luteum " to a degenerated con- 
dition sometimes met with in an unruptured Graafian follicle consisting 
in reabsorption of its contents and thickening of its walls (Plate III. Fig. 
3). It differs from the " true " corpus luteum in being deeply seated in 
the substance of the ovary, in having no central clot, and in being uncon- 
nected with a cicatrix on the surface of the ovary. Xor do obstetricians 
attach by any means the same importance as they did formerly to the 
presence of the corpus luteum as indicating impregnation ; for even 
when well marked, other and more reliable signs of recent delivery, 
such as enlargement of the uterus, are sure to be present, especially at 
the time when the corpus luteum has reached its maximum of develop- 
ment ; while after delivery at term it has no longer a sufficiently charac- 
teristic appearance to be depended on. 

Menstruation. — By the term menstruation (catamenia, periods, etc.) is 
meant the periodical discharge of blood from the uterus which occurs, 
in the healthy woman, every lunar month, except during pregnancy and 
lactation, when it is, as a rule, suspended. 

Period of Establishment. — The first appearance of menstruation coin- 
cides with the establishment of puberty, and the physical changes that 
accompany it indicate that the female is capable of conception and child- 
bearing, although exceptional cases are recorded in which pregnancy 
occurred before menstruation had begun. In temperate climates it gen- 
erally commences between the 14th and 16th years, the largest number 
of cases being met with in the 15th year. This rule is subject to many 
exceptions, it being by no means very rare for menstruation to become 
established as early as the 10th or 11th year, or to be, delayed until the 
18th or 20th. Beyond these physiological limits a few cases are from 
time to time met with in which it has begun in early infancy, or not 
until a comparatively late period of life. 

Influence of Climate, Race, etc. — Various accidental circumstances 
have much to do with its establishment. As a rule, it occurs somewhat 
earlier in tropical, and later in very cold than in temperate climates. 
The influence of climate has "been undulv exasperated. It used to be 
generally stated that in the Arctic regions women did not menstruate 
until they were of mature age, and that in the tropics, girls of 10 or 12 
years of age did so habitually. The researches of Robertson of Man- 
chester 2 first showed that the generally received opinions were erroneous; 
and the collection of a large number of statistics has corroborated his 
opinion. There can be no doubt, however, that a larger proportion of 
girls menstruate early in warm climates. Joulin found that in tropical 
climates, out of 1635 cases, the largest proportion began to menstruate 
between the 12th and 13th years; so that there is an average difference 
of more than two years between the period of its establishment in the 
tropics and in temperate countries. Harris 3 states that among the 

1 Op. cit., p. 64. 2 Edin. Med and Surg. Journ., 1832. 

3 Amer. Journ. of Obsiet., 1871, R. P. Harris on early puberty. 



86 ORGANS CONCERNED IN PARTURITION. 

Hindoos 1 to 2 per cent, menstruate as early as nine years of age ; 3 to 
4 per cent, at ten ; 8 per cent, at eleven ; and 25 per cent, at twelve ; 
while in London or Paris probably not more than one girl in 1000 or 
1200 does so at nine years. The converse holds true with regard to 
cold climates, although we are not in possession of a sufficient number 
of accurate statistics to draw very reliable conclusions on this point ; 
but out of 4715 cases, including returns from Denmark, Norway and 
Sweden, Russia, and Labrador, it was found that menstruation was 
established on an average a year later than in more temperate countries. 
It is probable that the mere influence of temperature has much to do in 
producing these differences, but there are other factors, the action of 
which must not be overlooked. Raciborski attributes considerable 
importance to the effect of race; and he has quoted Dr. Webb of 
Calcutta to the effect that English girls in India, although subjected to 
the same climatic influence as the Indian races, do not, as a rule, men- 
struate earlier than in England ; while in Austria girls of the Magyar 
race menstruate considerably later than those of German parentage. 1 
The surroundings of girls, and their manner of education and living, 
have probably also a marked influence in promoting or retarding its 
establishment. Thus, it will commence earlier in the children of the 
rich, who are likely to have a highly-developed nervous organization, 
and are habituated to luxurious living and a premature stimulation of 
the mental faculties by novel -reading, society, and the like; while 
amongst the hard-worked poor, or in girls brought up in the country, 
it is more likely to begin later. Premature sexual excitement is said 
also to favor its early appearance, and the influence of this among the 
factory-girls of Manchester, who are exposed in the course of their 
work to the temptations arising from the promiscuous mixing of the 
sexes, has been pointed out by Dr. Clay. 2 

[Precocious Physical Womanhood. — Within a few years the photo- 
graphic process has made us familiar with the appearances of several 
little girls of four, five, and six years of age who were menstruating 
regularly, had large mammse, and pubes covered with hair, all natives 
of our Northern States. In growth and obesity such children are far 
beyond their years as a general rule, but in mental development and 
character very child-like. Lately I saw one of six, who, although large, 
broad, and full-chested, and with arms and thighs like a woman, was 
playing with a doll and acting like a little girl of her own age ; another, 
of five and a half, was a beautiful miniature of a developing girl of twelve 
or fifteen ; and a third, of four, had breasts as large as an orange. For- 
tunately, the sexual passion, so general with the precociously-developed 
male infant, is seldom a marked characteristic in the female, although 
cases of precocity are much more frequently met with in girls. The 
nubile period has seldom been tested in these subjects, but occasionally 
in the lower classes of society, pregnancy has occurred at a very early 
age. Sue, in his Essais historiques,\f\ Paris, 1779, reports a ease where 
the young mother was eight years and ten months old, the fcetus being 
mature, but dead. Menstruation began at two years. Her mamma? 

1 Op. cit., p. 227. 2 Brit. Record of Obstet. Med., vol. i- 

[ 3 Vol. ii. p. 344.] 



OVULATION AND MENSTRUATION. 87 

and pubes resembled those of a girl of seventeen. The youngest mother 
in the United States was ten years and thirteen days old, four feet 
seven inches in height, and 100 pounds in weight. [ L ] She commenced 
to menstruate at one year; her child weighed 7f pounds. The youngest 
English mother was born on August 8, 1871 ; commenced to menstruate 
when a year old, and bore a child of 7 pounds in weight, after a labor 
of only 6 hours, in March, 1881. [ 2 ] She ceased to menstruate on June 
22, 1880, and must have become pregnant when eight years ten and a 
half months old. She was nine years seven and a half months old when 
her case was reported, March 24, 1881. 

A Southern negress just thirteen years old gave birth to a female 
child at maturity, who in turn became also pregnant at twelve. This 
child menstruated at ten years and nine months, and a second child at 
seven years and nine months. If the first daughter became a mother in 
due time, then the first-mentioned negress must have become a grand- 
mother before she was twenty-six. [ 3 ] 

A Spanish girl of Maracaibo is reported by the late Prof. C. D. 
Meigs to have given birth to a child at twelve, and twins at a second 
birth before she was fourteen. A quadroon of Xassau, New York, in 
1822, performed the Csesarean operation on herself when in labor with 
twins at the age of fourteen. — Ed.] 

Changes occurring at Puberty. — The first appearance of menstruation 
is accompanied by certain well-marked changes in the female system, on 
the occurrence of which we say that the girl has arrived at the period 
of puberty. The pubes becomes covered with hair, the breasts enlarge, 
the pelvis assumes its fully-developed form, and the general contour of 
the body fills out. The mental qualities also alter : the girl becomes 
more shy and retiring, and her whole bearing indicates the change that 
has taken place. The menstrual discharge is not established regularly 
at once. For one or two months there may be only premonitoiy symp- 
toms — a vague sense of discomfort, pains in the breasts, and a feeling of 
weight and heat in the back and loins. There then may be a discharge 
of mucus tinged with blood, or of pure blood, and this may not again 
show itself for several months. Such irregularities are of little con- 
sequence on the first establishment of the function, and need give rise to 
no apprehension. 

Period of Duration and Recurrence. — As a rule, the discharge recurs 
every twenty-eight days, and with some women with such regularity 
that they can foretell its appearance almost to the hour. The rule is, 
however, subject to very great variations. It is by no means uncom- 
mon, and strictly within the limits of health, for it to appear every 
twentieth day, or even with less interval ; while in other eases as much 
as six weeks may habitually intervene between two periods. The period 
of recurrence may also vary in the same subject. I am acquainted with 
patients who sometimes only have twenty-eight days, at others as many 
as forty-eight days, between their periods, without their health in any 
way suffering. Joulin mentions the ease of a lady who only menstru- 

1 Transylvania ~Med. Journ., vol. vii. p. 1 17. ] 

2 Lancet, April 9, 1881, p. 601.] 

3 Am. Journ. Obstetrics, vol. vi. p. 572, 1873-74.] 



88 ORGANS CONCERNED IN PARTURITION. 

ated two or three times in the year, and whose sister had the same 
peculiarity. 

The duration of the period varies in different women, and in the same 
woman at different times. In this country its average is four or five 
days, while in France, Dubois and Brierre de Boismont fix eight days as 
the most usual length. Some women are only unwell for a few hours, 
while in others the period may last many days beyond the average 
without being considered abnormal. 

Quantity of Blood lost. — The quantity of blood lost varies in different 
women. Hippocrates puts it at ^xviij, which, however, is much too 
high an estimate. Arthur Farre thinks that from §ij to ^iij is the full 
amount of a healthy period, and that the quantity cannot habitually 
exceed this without producing serious constitutional effects. Rich diet, 
luxurious living, and anything that unhealthily stimulates the body and 
mind will have an injurious effect in increasing the flow, w T hich is, 
therefore, less in hard-worked country-women than in the better classes 
and residents in towns. 

It is more abundant in warm climates, and our countrywomen in 
India habitually menstruate over-profusely, becoming less abundantly 
unwell when they return to England. The same observation has been 
made with regard to American women residing in the Gulf States, who 
improve materially by removing to the Lake States. Some women 
appear to menstruate more in summer than in winter. I am acquainted 
with a lady who spends the winter in St. Petersburg, where her periods 
last eight or ten days, and the summer in England, where they never 
exceed four or five. The difference is probably due to the effect of the 
overheated rooms in which she lives in Russia. 

The daily loss is not the same during the continuance of the period. 
It generally is at first slight, and gradually increases, so as to be most 
profuse on the second or third day, and as gradually diminishes. 
Toward the last days it sometimes disappears for a few hours, and 
then comes on again, and is apt to recur under any excitement or 
emotion. 

Quality of Menstrual Blood. — As the menstrual fluid escapes from 
the uterus it consists of pure blood, and if collected through the specu- 
lum it coagulates. The ordinary menstrual fluid does not coagulate 
unless it is excessive in amount. Various explanations of this fact 
have been given. It was formerly supposed either to contain no fibrin 
or an unusually small amount. Retzius attributes its non-coagulation 
to the presence of free lactic and phosphoric acids. The true explana- 
tion was first given by Mandl, who proved that even small quantities 
of pus or mucus in blood were sufficient to keep the fibrin in solution ; 
and mucus is always present to greater or less amount in the secretions 
of the cervix and vagina, which mix Avith the menstrual blood in its 
passage through the genital tract. If the amount of blood be excessive, 
however, the mucus present is insufficient in quantity to produce this 
effect, and coagula are then formed. 

On microscopic examination the menstrual fluid exhibits blood- 
corpuscles, mucous corpuscles, and a considerable amount of epithelial 
scales, the last being the debris of the epithelium lining the uterine 



OVULATION AND MENSTRUATION. 89 

cavity. According to Virchow, the form of the epithelium often proves 
that it comes from the interior of the utricular glands. The color of 
the blood is at first dark, and as the period progresses it generally 
becomes lighter in tint. In women who are in bad health it is often 
very pale. These differences doubtless depend upon the amount of 
mucus mingled with it. The menstrual blood has alwavs a character- 
istic, faint, and heavy odor, which is analogous to that which is so 
distinct in the lower animals during the rut. Raciborski mentions a 
lady who was so sensitive to this odor that she could always tell to 
a certainty when any woman was menstruating. It is attributed either 
to decomposing mucus mixed with the blood, which, when partially 
absorbed, may cause the peculiar odor of the breath often perceptible 
in menstruating women, or to the mixture with the fluid of the seba- 
ceous secretion from the glands of the vulva. It probably gave rise 
to the old and prevalent prejudices as to the deleterious properties of 
menstrual blood, which, it is needless to say, are altogether without 
foundation. 

Source of the Blood. — It is now universally admitted that the source 
of the menstrual blood is the mucous membrane lining the interior of 
the uterus, for the blood may be seen oozing through the os uteri by 
means of the speculum, and in cases of prolapsus uteri, while in cases 
of inverted uterus it may be actually observed escaping from tlie exposed 
mucous membrane, and collecting in minute drops upon its surface. 
During the menstrual nisus the whole mucous lining becomes congested 
to such an extent that, in examining the bodies of women who have died 
during menstruation, it is found to be thicker, larger, and thrown into 
folds, so as to completely fill the uterine cavity. The capillary circula- 
tion at this time becomes very marked, and the mucous membrane 
assumes a deep-red hue, the network of capillaries surrounding the ori- 
fices of the utricular glands being especially distinct. These facts have 
an unquestionable connection with the production of the discharge, but 
there is much difference of opinion as to the precise mode in which the 
blood escapes from the vessels. Coste believed that the blood transudes 
through the coats of the capillaries without any laceration of their struc- 
ture. Farre inclines to the hypothesis that the uterine capillaries ter- 
minate by open mouths, the escape of blood through these, between the 
menstrual periods, being prevented by muscular contraction of the ute- 
rine walls. Pouchet believed that during each menstrual epoch the 
entire mucous membrane is broken down and cast off in the form of 
minute shreds, a fresh mucous membrane being developed in the inter- 
val between two periods. During this process the capillary network 
would be laid bare and ruptured, and the escape of blood readily 
accounted for. Tyler Smith, who adopted this theory, states that he 
has frequently seen the uterine mucous membrane, in women who have 
died during menstruation, in a state of dissolution, with the broken loops 
of the capillaries exposed. The phenomena attending the so-called 
membranous dysmenorrhea, in which the mucous membrane is thrown 
oif in shreds or as a cast of the uterine cavity — the nature of which 
was first pointed out by Simpson and Oldham — have been supposed to 
corroborate this theory. This view is, in the main, corroborated by the 



90 ORGANS CONCERNED IN PARTURITION 

recent researches of Engelmann, 1 Williams, 2 and others. Williams de- 
scribes the mucous lining of the uterus as undergoing a fatty degenera- 
tion before each period, which commences near the inner os, and extends 
over the whole mucous membrane and down to the muscular wall. This 
seems to bring on a certain amount of muscular contraction, which drives 
the blood into the capillaries of the mucosa, and these, having become 
degenerated, readily rupture, and permit the escape .of the blood. The 
mucous membrane now rapidly disintegrates, and is cast off in shreds 
with the menstrual discharge, in which masses of epithelial cells may 
always be detected. Engelmann, however, holds that the fatty degenera- 
tion is limited to the superficial layers, and that a portion only of the 
epithelial investment is thrown off. As soon as the period is over the 
formation of a new mucous membrane is begun, from proliferation of 
the elements of the muscular coat, and at the end of a week the whole 
uterine cavity is lined by a thin mucous membrane. This grows until 
the advent of another period, when the same degenerative changes occur 
unless impregnation has taken place, in which case it becomes further 
developed into the decidua. 

Theory of Menstruation. — That there is an intimate connection be- 
tween ovulation and menstruation is admitted by most physiologists, 
and it is held by many that the determining cause of the discharge is 
the periodic maturation of the Graafian follicles. There is abundant 
evidence of this connection, for we know that when, at the change of 
life, the Graafian follicles cease to develop, menstruation is arrested ; 
and when the ovaries are removed by operation, of which there are now 
numerous cases on record, or when they are congenitally absent, men- 
struation does not generally take place. A few cases, however, have been 
observed in which menstruation continued after double ovariotomy or 
the removal of the ovaries by Battey's operation ; and these have been 
used as an argument by those physiologists who doubt the ovular theory 
of menstruation. Slavyanski has particularly insisted on such cases, 
which, however, are probably susceptible of explanation. It may be 
that the habit of menstruation may continue for a time even after the 
removal of the ovaries ; and it has not been shown that menstruation 
has continued permanently after double ovariotomy, although it cer- 
tainly has occasionally, although quite exceptionally, done so for a time. 
It is possible, also, that in such cases a small portion of ovarian tissue 
may have been left unremoved, sufficient to carry on ovulation. Roberts, 
a traveller quoted by Depaul and Gueniot in their article on " Menstrua- 
tion " in the Dictionnaire des Sciences Mgdicales, relates that in certain 
parts of Central Asia it is the custom to remove both ovaries in young 
girls who act as guards to the harems. These women, known as " hed- 
jeras," subsequently assume much of the virile type, and never menstru- 
ate. The same close connection between ovulation and the rut of ani- 
mals is observed, and supports the conclusion that the rut and menstru- 
tion are analogous. The chief difference between ovulation in man and 
the lower animals is that in the latter the process is not generally accom- 
panied by a sanguineous flow. To this there are exceptions, for in 

1 American Journal of Obstetrics, May, 1875. 

2 " On the Structure of the Mucous Membrane of the Uterus," Obst. Journ., 1875. 



OVULATION AND MENSTRUATION. 91 

monkeys there is certainly a discharge analogous to menstruation occur- 
ring at intervals. Another point of distinction is that in animals con- 
nection never takes place except during the rut, and that it is then only 
that the female is capable of conception ; while in the human race con- 
ception only occurs in the interval between the periods. This is another 
argument brought against the ovular theory, because, it is said, if men- 
struation depends on the rupture of a Graafian follicle and the emission 
of an ovule, then impregnation should only take place during or imme- 
diately after menstruation. Coste explains this by supposing that it is 
the maturation and not the rupture of the follicle which determines the 
occurrence of menstruation, and that the follicle may remain unrup- 
tured for a considerable time after it is mature, the escape of the ovule 
being subsequently determined by some accidental cause, such as sexual 
excitement. However this may be, there is good reason to believe that 
the susceptibility to conception is greater during the menstrual epochs. 
Raciborski believes that in the large proportion of cases impregnation 
occurs in the first half of the menstrual interval, or in the few days im- 
mediately preceding the appearance of the discharge. There are, how- 
ever, very numerous exceptions, for in Jewesses, who almost invariably 
live apart from their husbands for eight days after the cessation of men- 
struation, impregnation must constantly occur at some other period of 
the interval, and it is certain that they are not less prolific than other 
people. This rule with them is very strictly adhered to, as will be seen 
by the accompanying interesting letter from a medical friend who is a 
well-known member of that community, and which I have permission 
to publish. 1 This fact is of itself sufficient to disprove the theory 

1 10 Bernard Street, Russell Square, July 21, 1873. 
My Dear Sir: 

1. To the best of my knowledge and belief, the law which prohibits sexual inter- 
course among Jews for seven clear days after the cessation of menstruation, is 
almost universally observed, the exceptions not being sufficient to vitiate statistics. 
The law has perhaps fewer exceptions on the Continent — especially Russia and Poland, 
where the Jewish population is very great — than in England. Even here, however, 
women who observe no .other ceremonial law observe this, and cling to it after every- 
thing else is thrown overboard. There are doubtless many exceptions, especially 
among the better classes in England, who keep only three days after the cessation of 
the menses. 

2. The law is — as you state — that should the discharge last only an hour or so, or 
should there be only one gush or one spot on the linen, the live days during which the 
period might continue are observed ; to which must be superadded the seven clear days 
— twelve days per mensem in which connection is disallowed. Should any discharge 
be seen in the inter-menstrual period, seven days would have to be kept, but not the 
five, for such irregular discharge. 

3. The "bath of purification," which must contain at least eighty gallons, is used on 
the last night of the seven clear days. It is not used till after a bath for cleansing pur- 
poses; and, from the night when such "purifying" bath is used Jewish women are 
accustomed to calculate the commencement of pregnancy. That you should not have 
heard it is not strange: its mention would be considered highly indelicate. 

4. Jewish women reckon their pregnancy to last nine calendar or ten lunar months 
— 270 to 280 days. There are no special data on which to reckon an average, nor do 
I know of any books on the subject, except some Talmudic authorities, which I will 
look up for you if you desire it. Pray make no apologies for writing to me: any in- 
formation I possess is at your service. 

I am, dear sir. yours very truly, 
Dr. Play fair. * A." A -in 

P. S. — The biblical foundation for the law of seven clear days is Leviticus XV., verse 
19 to the end of the chapter— especially verse 28. 



92 ORGANS CONCERNED IN PARTURITION. 

advanced by Dr. Avrard, 1 that impregnation is impossible in the latter 
half of the menstrual interval. This, and the other reasons referred to, 
undoubtedly throw some doubt on the ovular theory, but they do not 
seem to be sufficient to justify the conclusion that menstruation is a 
physiological process altogether independent of the development and 
maturation of the Graafian follicles. All that they can be fairly held 
to prove is that the escape of the ovules may occur independently of 
menstruation, but the weight of evidence remains strongly in favor of 
the theory which is generally received. It should be stated that Lawson 
Tait attributes considerable influence in menstruation to the Fallopian 
tubes themselves ; but his views on this point, based on observations 
made after the removal of the ovaries for certain morbid conditions, 
cannot yet be taken as proved. 

Purpose of the Menstrual Loss. — The cause of the monthly periodicity 
is quite unknown, and will probably always remain so. Goodman 2 has 
suggested what he calls the " cyclical theory of menstruation," which 
refers the phenomena to a general condition of the vascular system 
specially localizing itself in the generative organs, and connected with 
rhythmical changes in their nerve-centres. It does not seem to me, 
however, that he has satisfactorily proved the recurrence of the condi- 
tions which his ingenious theory assumes. The purpose of the loss of 
so much blood is also somewhat obscure. To a certain extent it must 
be considered an accident or complication of ovulation, produced by the 
vascular turgescence. Nor is it essential to fecundation, because women 
often conceive during lactation, when menstruation is suspended or 
before the function has become established. It may, however, serve the 
negative purpose of relieving the congested uterine capillaries which are 
periodically tilled with a supply of blood for the great growth which 
takes place when conception has occurred. Thus immediately before 
each period the uterus may be considered to be placed by the afflux of 
blood in a state of preparation for the function it may be suddenly called 
upon to perform. That the discharge relieves a state of vascular ten- 
sion which accompanies ovulation is proved by the singular phenomenon 
of vicarious menstruation which is occasionally, though rarely, met with. 
It occurs in cases in which, from some unexplained cause, the discharge 
does not escape from the uterine mucous membrane. Under such cir- 
cumstances a more or less regular escape of blood may take place from 
other sites. The most common situations are the mucous membranes of 
the stomach, of the nasal cavities, or of the lungs ; the skin, not uncom- 
monly that of the mammae, probably on account of their intimate sym- 
pathetic relation with the uterine organs ; from the surface of an ulcer ; 
or from hemorrhoids. It is a noteworthy fact that in all these cases the 
discharge occurs in situations where its external escape can readily take 
place. This strange deviation of the menstrual discharge may be taken 
as a sign of general ill-health, and it is usually met with in delicate 
young women of highly mobile nervous constitution. It may, however, 
begin at puberty, and it has even been observed during the whole sexual 
life. The recurrence is regular, and always in connection with the men- 

1 Rev. cle. Therap. Med.-Chir., 1857. 

2 American Journal of Obstetrics, Oct., 1868. 



OVULATION AND MENSTRUATION. 93 

strual nisus, although the amount of blood lost is much less than in 
ordinary menstruation. 

Cessation of Menstruation. — After a certain time changes occur, show- 
ing that the woman is no longer fitted for reproduction ; menstruation 
ceases, Graafian follicles are no longer matured, and the ovary becomes 
shrivelled and wrinkled on its surface. Analogous alterations take 
place in the uterus and its appendages. The Fallopian tubes atrophy, 
and are not unfrequently obliterated. The uterus decreases in size. 
The cervix undergoes a remarkable change, which is readily detected on 
vaginal examination ; the projection of the cervix into the vaginal canal 
disappears, and the orifice of the os uteri in old women is found to be 
flush with the roof of the vagina. In a large number of cases there is, 
after the cessation of menstruation, an occlusion both of the external and 
internal os ; the canal of the cervix between them, however, remains 
patulous, and is not unfrequently distended with a mucous secretion. 

Period of Cessation. — The age at which menstruation ceases varies 
much in different women. In certain cases it may cease at an unusually 
early age, as between 30 and 40 years, or it may continue far beyond 
the average time, even up to 60 years ; and exceptional, though perhaps 
hardly reliable, instances are recorded in which it has continued even 
to 80 or 90 years. These are, however, strange anomalies, which, like 
cases of unusually precocious menstruation, cannot be considered as hav- 
ing any bearing on the general rule. Most cases of so-called protracted 
menstruation will be found to be really morbid losses of blood depend- 
ing on malignant or other forms of organic disease, the existence of 
which, under such circumstances, should always be suspected. 

In this country menstruation usually ceases between 40 and 50 years 
of age. Eaciborski says that the largest number of cases of cessation 
are met with in the 46th year. It is generally said that women who 
commence to menstruate when very young cease to do so at a compara- 
tively early age, so that the average duration of the function is about 
the same in all Avomen. Cazeaux and Raciborski, whose opinion is 
strengthened by the observations of Guy in 1500 cases, 1 think, on the 
contrary, that the earlier menstruation commences the longer it lasts, 
early menstruation indicating an excess of vital energy which continues 
during the whole childbearing life. Climate and other accidental causes 
do not seem to have as much effect on the cessation as on the establish- 
ment of the function. It does not appear to cease earlier in warm than 
in temperate climates. The change of life is generally indicated by 
irregularities in the recurrence of the discharge. It seldom ceases sud- 
denly, but it may be absent for one or more periods, and then occur 
irregularly; or it may become profuse or scanty, until eventually it 
entirely stops. The popular notions as to the extreme danger of the 
menopause are probably much exaggerated, although it is certain that at 
that time various nervous phenomena are apt to be developed. So far 
from having a prejudicial effect on the health, however, it is not an un- 
common observation to see an hysterical woman, who has been for years 
a martyr to uterine and other complaints, apparently take a new lease 
of life when her uterine functions have ceased to be in active operation ; 

1 Med. Times and Gaz., 1845. 



94 ORGANS CONCERNED IN PARTURITION. 

and statistical tables abundantly prove that the general mortality of the 
sex is not greater at this than at any other time. 

[The theory that the average duration of menstrual life is thirty 
years, and that the period of cessation is usually regulated by the age at 
which menstruation was established, is an error. The age of cessation 
is much more irregular than that of commencement, and women cease to 
menstruate at all ages from 28 to 56, and even beyond 60. If careful 
inquiry is made, especially among women in the higher walks of life, it 
will be found that those who begin to menstruate at 9, 10, 11, and 12 
years of age often continue to do so until long after thirty years have 
passed, and that it is not uncommon for such women to be among the 
latest in reaching the menopause. I have known the menopause to be 
established before 30, and menstruation to be still regular at 62 years 
of age. — Ed.] 



PART II. 

PREGNANCY, 



CHAPTER I. 
CONCEPTION AND GENEKATION. 

Generation in the human female, as in all mammals, requires the 
congress of the two sexes, in order that the semen, the male element of 
generation, may be brought into contact with the ovule, the female ele- 
ment of generation. 

The Semen. — The semen secreted by the testicle of an adult male is a 
viscid, opalescent fluid, forming an emulsion when mixed with water, 
and having a peculiar faint odor, which is attributed to the secretions 
which are mixed with it, such as those from the prostate and Cowper's 
glands. On analysis it is found to be an albuminous fluid, holding in 
solution various salts, principally phosphates and chlorides, and an ani- 
mal substance, spermatin, analogous to fibrin. Examined under a mag- 
nifying power of from 400 to 500 diameters, it consists of a transparent 
and homogeneous fluid, in Avhich are floating a certain number of gran- 
ules and epithelial cells derived from the secretions mixed with it, and 
the characteristic sperm-cells and spermatozoa which form its essential 
constituents. The sperm-cells are those occupying the tubuli semeniferi 
of the testicle. Several kinds of sperm-cells are described which receive 
their name from the position they occupy with regard to the lumen of 
the tubule (Fig. 44). The cells which are next to the wall of the tubule 
are called the outer or lining cells. They are more or less flattened in 
form, and are situated on a distinct basement membrane. Internal to 
this layer is another, consisting of round cells, the nuclei of which are 
in a state of proliferation ; this is the intermediate layer. Between this 
and the lumen of the tubule are a number of cells, irregular in shape, 
amongst which are imbedded the heads of the spermatozoa, the tails of 
which project into the lumen. The spermatozoa are thought to arise 
from this innermost layer in the following manner: the nuclei of the 
sperm-cells proliferate, and from their subdivisions arise the heads of 
the spermatozoa, the bodies of which originate from the protoplasm of 
the cells. By the decomposition of the substance in which the heads of 
the spermatozoa are imbedded the contained spermatozoa become liberated, 
and move about freely in the seminal fluid. As seen under the micro- 
scope, the spermatozoa, which exist in healthy semen in enormous num- 
bers, present the appearance of minute particles, not unlike a tadpole in 

95 



96 



PREGNANCY. 



shape. The head is oval and flattened, measuring about y o^qt °f an 
inch in breadth, and attached to it is a delicate filamentous expansion or 
tail, which tapers to a point so fine that its termination cannot be seen 
by the highest powers of the microscope. The whole spermatozoon 
measures from -^-^ to -g-^-Q of an inch in length. The spermatozoa are 
observed to be 'in constant motion, sometimes very rapid, sometimes more 

Fig. 44. 




Section of Parts of three Semeniferous Tubules of the Rat. 
o. With the spermatozoa least advanced in development, b. More advanced, c. Containing fully-developed 
spermatozoa. Between the tubules are seen strands of interstitial cells and lymph -spaces. (From a prepara- 
tion by Mr. A. Frazer.) 

gentle, which is supposed to be the means by which they pass upward 
through the female genital organs. They retain their vitality and power 
of movement for a considerable time after emission, provided the semen 
is kept at a temperature similar to that of the body. Under such cir- 
cumstances they have been observed in active motion from forty-eight to 
seventy-two hours after ejaculation, and they have also been seen alive 
in the testicle as long as twenty-four hours after death. In all proba- 
bility they continue active much longer within the generative organs, as 
many physiologists have observed them in full vitality in bitches and 
rabbits seven or eight days after copulation. The recent experiments of 
Haussman, however, show that they lose their power of motion in the 
human vagina within twelve hours after coitus, although they doubtless 
retain it longer in the uterus and Fallopian tubes. Abundant leucor- 
rheal discharges and acrid vaginal secretions destroy their movements, 
and may thus cause sterility in the female. On account of their mobility, 
the spermatozoa were long considered to be independent animalcules — 
a view which is by no means exploded, and has been maintained in mod- 
ern times by Pouchet, Joulin, and other writers, while Coste, Robin, 
Kolliker, etc. liken their motion to that of ciliated epithelium. There 
can be no doubt that the fertilizing power of the semen is due to the 
presence of the spermatozoa, although some of the older physiologists 
assigned it to the spermatic fluid. The former view, however, has been 



CONCEPTION AND GENERATION. 97 

conclusively proved by the experiments of Prevost and Dumas, who 
found that on carefully removing the spermatozoa by nitration the semen 
lost its fecundating properties. 

Sites of Impregnation. — There has been great difference of opinion as 
to the part of the genital tract in which the spermatozoa and the ovule 
come into contact, and in which impregnation, therefore, occurs. Sperma- 
tozoa have been observed in all parts of the female genital organs in 
animals killed shortly after coitus, especially in the Fallopian tubes, and 
even on the surface of the ovary. The phenomena of ovarian gestation, 
and the fact that fecundation has been proved to occur in certain animals 
within the ovary, tend to support the idea that it may also occur in the 
human female before the rupture of the Graafian follicle. In order to 
do so, however, it is necessary for the spermatozoa to penetrate the proper 
structure of the follicle and the epithelial covering of the ovary, and no 
one has actually seen them doing so. Most probably the contact of the 
spermatozoa and the ovule occurs very shortly after the rupture of the 
follicle, and in the outer part of the Fallopian tubes. Coste maintains 
that unless the ovule is impregnated it very rapidly degenerates after 
being expelled from the ovary, partly by inherent changes in the ovule 
itself, and partly because it then soon becomes invested by an albuminous 
covering which is impermeable to the spermatozoa. He believes, there- 
fore, that impregnation can only occur either on the surface of the ovary 
or just within the fimbriated extremity of the tube. 

Mode in ivhich the Ascent of the Semen is Effected. — The semen is proba- 
bly carried upward chiefly by the inherent mobility of the spermatozoa. 
It is believed by some that this is assisted by other agencies : amongst 
them are mentioned the peristaltic action of the uterus and Fallopian 
tubes ; a sort of capillary attraction effected when the Avails of the 
uterus are in close contact, similar to the move- 
ment of fluid in minute tubes ; and also the 
vibratile action of the cilia of the epithelium 
of the uterine mucous membrane. The action 
of the latter is extremely doubtful, for they 
are also supposed to effect the descent of the 
ovule, and they can hardly act in two oppo- 
site ways. The movement of the cilia being 
from within outward, it would certainly 
oppose rather than favor the progress of the 
spermatozoa. It must, therefore, be admitted 
that they ascend chiefly through their own 
powers of motion. They certainly have this Ovum of Rabbit 




contauiii 



Spermatozoa. 
power to a remarkable extent, for there are ,. Zona pellu J ida . 2 . T i,e germs, con- 

numerous cases on record in which imprep;- ■hung ° f t wo 'wge ceils, several 

. , , . , l ~ 1 smaller cells, and .spermatozoa. 

nation has occurred without penetration, and 

even when the hymen was quite entire, and in which the semen has sim- 
ply been deposited on the exterior of the vulva ; in such cases, which 
are far from uncommon, the spermatozoa must have found their way 
through the whole length of the vagina. It is probable, however, that 
under ordinary circumstances the passage of the spermatic fluid into the 
uterus is facilitated by changes which take place in the cervix during 
7 



98 PREGNANCY. 

the sexual orgasm, in the course of which the os uteri is said to dilate 
and close again in a rhythmical manner. 1 

Mode of Impregnation. — The precise method, in which the spermatozoa 
effect impregnation was long a matter of doubt. It is now, however, 
certain that they actually penetrate the ovule and reach its interior. 
This has been conclusively proved by the observations of Barry, Meiss- 
ner, and others, who have seen the spermatozoa within the external 
membrane of the ovule in rabbits (Fig. 45). In some of the inverte- 
brata a canal or opening exists in the zona pellucida, through which the 
spermatozoa pass. No such aperture has yet been demonstrated in the 
ovules of mammals, but its existence is far from improbable. Accord- 
ing to the observations of Newport, several spermatozoa enter the ovule, 
and the greater the number that do so the more certain fecundation be- 
comes. After the spermatozoa penetrate the zona pellucida, they disin- 
tegrate and mingle with the yelk, having, while doing so, imparted to 
the ovule a power of vitality and initiated its development into a new 
being. 

Progress of the Impregnated Ovule toward the Uterus. — The length of 
time which lapses before the fecundated ovule arrives in the cavity of 
the uterus has not yet been ascertained, and it probably varies under 
different circumstances. It is known that in the bitch it may remain 
eight or ten days in the Fallopian tube, in the guinea-pig three or four. 
In the human female the ovum has never been discovered in the cavity 
of the uterus before the tenth or twelfth day after impregnation. 

Changes ivhich the Ovule undergoes immediately before and after Im- 
pregnation. — The changes which occur in the human ovule immediately 
before and after impregnation, and during its progress through the Fal- 
lopian tube, are only known to us by analogy, as, of course, it is impos- 
sible to study them by actual observation. We are in possession, how T - 
ever, of accurate information of what has been made out in the lower 
animals, and it is reasonable to suppose that similar changes occur in 
man. Immediately after the ovule has passed into the Fallopian tube, 
it is found to be surrounded by a layer of granular cells, a portion of 
the lining membrane of the Graafian follicle, which was described as 
the discus proligerus. As it proceeds along the tube, these surrounding 
cells disappear — partly, it is supposed, by friction on the walls of the 
tube, and partly by being absorbed to nourish the ovule. Be this as it 
may, before long they are no longer observed, and the zona pellucida 
forms the outermost layer of the ovule. When the ovule has advanced 
some distance along the tube, it becomes invested with a covering of 
albuminous material, which is deposited around it in successive layers, 
the thickness of which varies in different animals. It is very abundant 
in birds, in whom it forms the familiar white of the egg. In some 
animals it has not been detected, so that its presence in the human ovule 
is uncertain. Where it exists it doubtless contributes to the nourishment 
of the ovule. Coincident with these changes is the disappearance of the 
germinal vesicle. At the same time the yelk contracts and becomes 
more solid, retiring from close contact with the zona pellucida, and 
thus forming a species of cavity between the outer edge of the yelk and 
1 How do the Spermatozoa enter the Uterus ? by J. Beck, M. D. 



CONCEPTION AND GENERATION. 



99 



the vitelline membrane, which in some animals is filled with a trans- 
parent liquid. Coincident with the shrinking of the yelk, a small 
granular mass of a rounded form is ex- 
truded from the yelk into the clear space 
beneath the zona pellucida. At a later 
period another similar mass is extruded. 
These are the polar globules (Fig. 46), the 
origin of which is thought to be in con- 
nection with the disappearance of the ger- 
minal vesicle and the germinal spot. These 
changes occur in all ovules, whether they 
are impregnated or not, but if the ovule 
is not fecundated, no further alterations 
occur. Supposing impregnation has taken 
place, a bright, clear vesicle, called the 
vitelline nucleus, very similar in appearance 
to a drop of oil, appears in the centre of 
the yelk. After this occurs the very peculiar phenomenon known as 
the cleavage of the yelk, which results in the formation of the layer of 
cells from which the foetus is developed. The segmentation of the yelk 
(Fig. 47) occupies in mammals the whole of its substance. In birds the 
cleavage is confined to a small area of the yelk called the cicatricula or 
blastoderm. Hence the term holoblastic has been applied to the ova of 
mammals, mesoblastic to those of birds. It divides at first into two 




Formation of the " Polar Globule." 
Zona pellucida, containing spermatozoa. 
2. Yelk. 3 and 4. Germinal vesicle. 5. 
The polar globule. 




Ovum with first embryo cell. 



Segmentation of the Yelk. 
Division of embryo cell and cleavage of the yelk around it. 
Further division of the yelk. 



halves, and at the same time the vitelline nucleus becomes constricted 
in its centre, and separates into two portions, one of which forms a cen- 
tre for each of the halves into which the yelk has divided. Each of' 
these immediately divides into two, as does its contained portion of tlio 
vitelline nucleus, and so on in rapid succession until the whole yelk is 
divided into a number of spheres, each of which consists of a clump of 
nucleated protoplasm. 

By these continuous dichotomous divisions the whole yelk is formed 



100 



PREGNANCY. 



into a granular mass, which from its supposed resemblance to a mulberry 
has been named the muriform body. When the subdivision of the yelk 
is completed, its separate spheres become converted into cells, consisting 
of a fine membrane with granular contents. These cells unite by their 
edges to form a continuous membrane (Fig. 48), which, through the 
expansion of the muriform body by fluid which forms in its interior, is 
distended until it forms a lining to the zona pellucida. This is the 
blasterdomic membrane, from which the foetus is developed. By this 
time the ovum has reached the uterus ; and before proceeding to con- 
sider the further changes which it undergoes, it will be well to study 
the alteration which the stimulus of impregnation has set on foot in the 
mucous membrane of the uterus, in order to prepare it for the reception 
and growth of its contents. 

Fig. 48. 




Formation of the Blastodermic Membrane from the Cells of the Muriform Body. (After Joulin.) 
1. Layer of albuminous material surrounding 2. The zona pellucida. 



Changes in the Uterine Mucous Membrane consequent on Pregnancy. — 
— Even before the ovum reaches the uterus the mucous membrane be- 
comes thickened and vascular, so that its opposing surfaces entirely fill 
the uterine cavity. These changes may be said to be the same in kind 
— although more marked and extensive in degree — as the alterations 
which take place in the mucous membrane in connection with each 
menstrual period. The result is the formation of a distinct membrane, 
which affords the ovum a safe anchorage and protection until its connec- 
tions with the uterus are more fully developed. After delivery, (his 
membrane, which is by that time quite altered in appearance, is at least 
partially thrown off with the ovum ; on which account it has received 
the name of the decidua or caduca. 

Divisions of the Decidua. — The clecidua consists of two principal por- 
tions, which in early pregnancy are separated from each other by a con- 
siderable interspace. One of these, called the decidua vera, lines the 
entire uterine cavity, and is, no doubt, the original mucous lining of the 



CONCEPTION AND GENERATION 101 

uterus greatly hypertrophied. The second, the decidua reflexa, is closely 
applied round the ovum, and it is probably formed by the sprouting of 
the decidua vera around the ovum at the point on which the latter rests, 
so that it eventually completely surrounds it. As the ovum enlarges, 
the decidua reflexa is necessarily stretched, until it comes everywhere 
into contact with the decidua vera, w T ith which it firmly unites. After 
the third month of pregnancy true union has occurred, and the two 
layers of decidua are no longer separate. The decidua serotina, which 
is described as a third portion, is merely that part of the decidua vera 
on which the ovum rests and where the placenta is eventually developed. 
Views of William arid John Hunter. — It is needless to refer to the 
various views wdiich have been held by anatomists as to the structure 
and formation of the decidua. That taught by John Hunter was long 
believed to be correct, and down to a recent date it received the adhe- 
rence of most physiologists. He believed the decidua to be an inflamma- 
tory exudation, which on account of the stimulus of pregnancy was 
thrown out all over the cavity of the uterus, and soon formed a distinct 
lining membrane to it. When the ovum reached the uterine orifice of 
the Fallopian tube it found its entrance barred by this new membrane, 
which accordingly it pushed before it. This separated portion formed a 
covering to the ovum and became the decidua reflexa, while a fresh exu- 
dation took place at that portion of the uterine wall which w r as thus laid 
bare, and this became the decidua vera. William Hunter had much 
more correct views of the decidua, the accuracy of which was at the 
time much contested, but which have recently received full recognition. 
He describes the decidua in his earlier writings as a hypertrophy of the 
uterine mucous membrane itself — a view which is now held by all 
physiologists. 

Structure of the Decidua. — When the decidua is first formed, it is a 
hollow triangular sac lining the uterine cavity (Fig. 49), and having 
three openings into it — those of the Fallopian tubes at its upper angles, 
and one, corresponding to the internal os uteri, below. If, as is gener- 
ally the case, it is thick and pulpy, these openings are closed up and 
can no longer be detected. In early pregnancy it is well developed, and 
continues to grow up to the third month of utero-gestation. After that 
time it commences to atrophy, its adhesion with the uterine walls less- 
ens, it becomes thin and transparent, and is ready for expulsion when 
delivery is effected. When it is most developed, a careful examination 
of the decidua enables us to detect in it all the elements of the uterine 
mucous membrane greatly hypertrophied. Its substance chiefly consists 
of large round or oval nucleated cells and elongated fibres, mixed with 
the tubular uterine gland-ducts, which are much elongated, and filled 
with cylindrical epithelium cells and a small quantity of milky fluid. 
According to Friedlander, the decidua is divisible into two layers : the 
inner, being formed by a proliferation of the corpuscles of the sub-epi- 
thelial connective tissue of the mucous membrane; the deeper, in contact 
with the uterine walls, out of flattened or compressed gland-ducts. In 
an early abortion the extremities of these ducts may be observed by a 
lens, on the external or uterine surface of the decidua, occupying the 
summit of minute projections separated from each other by depression-. 



102 



PREGNANCY. 



If these projections be bisected they will be found to contain little cavi- 
ties, filled with lactescent fluid, which were first described by Montgom- 
ery of Dublin, and are known as Montgomery's cups. They are in fact 



Fig. 49. 




Aborted Ovum of about forty days, showing the Triangular Shape of the Decidua (which is laid 
open), and the Aperture of the Fallopian Tube. (After Coste.) 

the dilated canals of the uterine tubular glands. On the internal surface 
of such an early decidua a number of shallow depressions may be made 
out, which are the open mouths of these ducts. 



Fig. 50. 



Fig. 51. 



Fig. 52. 






Formation of Decidua. 
(The decidua is colored black ; 
the ovum is represented as 
engaged between two pro- 
jecting folds of membrane.) 



Projecting Folds of Mem- 
brane growing up around 
the Ovum. 



(After Dalton.) 



Showing Ovum completely sur- 
rounded by the Decidua Re- 
flexa. 



Formation of the Decidua Reflexa. — When the ovum reaches the ute- 
rine cavity, it soon becomes imbedded in the folds of the hypertrophied 
mucous membrane, which almost entirely fills the uterine cavity. As a 



COXCEPTIOX AND GENERATION. 103 

rule, it is attached to some point near the opening of a Fallopian tube, 
the swollen folds of mucous membrane preventing its descent to the 
lower part of the uterus ; in exceptional circumstances, however — as in 
women who have borne many children and have a more than usually 
dilated uterine cavity — it may fix itself at a point much nearer the 
internal os uteri. According to the now generally accepted opinion of 
Coste, the mucous membrane at the base of the ovum soon begins to 
sprout around it, and gradually extends until it eventually covers the ovum 
(Figs. 50-52) and forms the decidua reflexa. Coste describes, under 
the name of the umbilicus, a small depression at the most prominent part 
of the ovum, which he considers to be the indication of the point where 
the closure of the decidua reflexa is effected. There are some objections 
to this theory, for no one has seen the decidua reflexa incomplete and in 
the process of formation, and on examining its external surface — that is, 
the one farthest from the ovum — its microscopical appearance is identi- 

Fig. 53. 




An Ovum removed from Uterus, and part of the Decidua Vera cut away. (After Coste.) 

a. Decidua vera, showing the follicles opening on its inner surface /<. Inner extremity of Fallopian tube. 

c. Flap of decidua reflexa. d. Ovum. 

cal with that of the inner surface of the decidua vera. To meet these 1 
difficulties, Weber and Goodsir, whose views have been adopted by 
Priestley, contended that the decidua reflexa is "the primary lamina of 
the mucous membrane, which, when the ovum enters the uterus, sepa- 
rates in two-thirds of its extent from the layers beneath it, to adhere to 
die ovum ; the remaining third remains attached, and forms a centre of 
nutrition." According to this view, the decidua vera would be a sub- 
sequent growth over the separated portion, and the decidua semtiua the 
portion of the primary lamina which remained attached. In this way 
the fact of the opposed surfaces of the decidua vera and reflexa being 
identical in structure would be accounted for. The difficulty which this 
thco-v is thus intended to meet doe- not seem so greal a- is supposed ; 
for if, as is likely, it is only the epithelial op internal surface of the 
mucous membrane which sprouts over the ovum, and n.-t it- deeper 
layers,, the facts of the case would he sufficiently met by Coste's view. 



104 PREGNANCY. 

Up to the third month of pregnancy the decidua reflexa and vera are 
not in close contact, and there may even be a considerable interspace be- 
tween them, which sometimes contains a small quantity of mucous fluid, 
called the hydroperione. This fact may account for the curious circum- 
stance, of which many instances are on record, that a uterine sound may 
be passed into a gravid uterus in the early months of pregnancy without 
necessarily producing abortion, and also for the occasional occurrence of 
menstruation after conception (Figs. 53 and 80). Eventually, by the 
growth of the ovum, the decidua reflexa comes closely into contact with 
the vera, and the two become intimately blended and inseparable. 

Decidua at the End of Pregnancy and after Delivery. — As pregnancy 
advances, the decidua alters in appearance and becomes fibrous and thin. 
In the later months of utero-gestation fatty degeneration of its structure 
commences, its vessels and glands are obliterated, and its adhesion to the 
uterine walls is lessened, so as to prepare it for separation. As Aye shall 
subsequently see, this fatty degeneration was assumed by Simpson to be 
the determining cause of labor at term. After the eighth month, thrombi 
form in the veins lying underneath the decidua serotina, and at the end 
of pregnancy they are described by Leopold 1 as having become, to a 
great extent, obliterated. This, he supposes, may have some effect in 
inducing the contractions of the uterus in labor. 

Vieics of Robin. — It was long believed that the entire decidua was 
thrown off after labor, leaving the muscular coat of the uterus bare and 
denuded, and that a new mucous membrane was formed during con- 
valescence. According to Robin, 2 whose views are corroborated by 
Priestley, no such denudation of the muscular tissue of the uterus ever 
occurs, but a portion of the decidua always remains attached after 
delivery. After the fourth month of pregnancy they believe that a new 
mucous membrane is formed under the decidua, which remains in a 
somewhat imperfect condition till after delivery, when it rapidly 
develops and assumes the proper functions of the mucous lining of 
the uterus. Robin also believes that that portion of the decidua which 
covers the placental site, the so-called decidua serotina, is not thrown 
off with the membranes, like the decidua vera and reflexa, but remains 
attached to the uterine walls, a thin layer of it only being expelled with 
the placenta, on which it may be observed. Duncan 3 entirely dissents 
from these views, and does not admit the formation of a new mucous 
membrane during the later months of utero-gestation. He believes that 
the greater part of the decidua is thrown off, but that part remains, and 
from this the fresh mucous membrane is developed. This view is sim- 
ilar to that of Spiegelberg, who holds that the portion of the decidua 
that is expelled is the more superficial of the two layers described by 
Friecllander, composed chiefly of the epithelial elements, while the 
deeper or glandular layer remains attached to the walls of the uterus. 
From the epithelium of the glands a new epithelial layer is rapidly 
developed after delivery. Leopold 4 has shown that the uterine mucous 
membrane is completely re-formed within six weeks after delivery, and 
that its regeneration is sometimes completed as early as the end of the 

1 Arch.f. Gi/n., B. xi. H. 3. a Memoires de PAcad. Imp. de Med., 1861. 

3 Researches in Obstetrics, p. 186 et seq. * Arch. f. Gyn., B. xii. H. 2. 



COXCEPTIOX AXD GENERATION. 105 

third week. This theory bears on the well-known analogy of the 
uterus after delivery to the stump of an amputated limb — an old simile, 
principally based on the erroneous theory that the whole muscular tissue 
of the uterus was laid bare. This, as we have seen, is not the case, but 
the simile so far holds good in that the mucous lining is deprived of its 
epithelial covering ; and this fact, together with the existence of numer- 
ous open veins on the interior of the uterus, readily explains the extreme 
susceptibility to septic absorption which forms so peculiar a character- 
istic of the puerperal state. 

Changes in the Ovum. — Before we commenced the study of the 
decidua we had traced the impregnated ovum into the uterine cavity, 
and described the formation of the blastodermic membrane by the junc- 
tion of the cells of the muriform body. "We must now proceed to con- 
sider the further changes which result in the development of the foetus 
and of the membranes that surround it. It would be quite out of place 
in a work of this kind to enter into the subject of embryology at any 
length, and we must therefore be content with such details as are of 
importance from a practical point of view. 

Division of the Blastodermic Membrane into Layers. — The blasto- 
dermic membrane, which forms a complete spherical lining to the 
ovum between the yelk and the zona pellucida, soon divides into two 
layers — the most external, called the epiblast, and an internal, the hypo- 
blast — and between them is subsequently developed a third, known as 
the mesoblast. From these three layers are formed the entire foetus : 
the epiblast giving origin to the central nervous system, to the super- 
ficial layer of the skin, and aiding in formation of the organs of special 
sense and of the amnion ; the hypoblast forming the epithelial lining 
membrane of the alimentary and respiratory tracts, and of the tubes and 
glands in connection with them, and helping in the development of the 
yelk-sac; the mesoblast giving rise to the skeleton, the muscles, the 
connective tissues, the vascular system, the genito-urinary organs, and 
taking part in the formation of all the membranes. 

The Area Germinativa. — Almost immediately after the separation of 
the blastodermic membrane into lay- 
ers one part of it becomes thickened 
by the aggregation of cells, and is 
called the area germinativa. This 
is at first round and then oval in 
shape, and in its centre the first 
indication of the embryo may be 
detected in the form of a narrow 
straight line, the primitive trace. 
Surrounding it are some cells more 
translucent than those of the rest 
of the area germinativa, and hence 
called the area pellucida ( Fig. 54). 
In front of the primitive trace two 

elevated ridges soon arise, the lam- Diagram of Area Germinativa, showing the 

, j & . . , . , , ' , Primitive Trace and Ana ivilucida. 

■hid dorsaleSj winch include between 

them a groove — the medullary groove — and gradually unite posteriorly 




106 



PREGNANCY. 



Fig. 55. 



'"fcSt^C^o 



to form a cavity within which the cerebro-spinal axis is subsequently 
developed. The medullary groove as it grows backward overlaps the 
primitive trace, which disappears. The embryo is differentiated from 
the rest of the blastoderm by a fold anteriorly, which is called the 
cephalic or head fold. Another fold afterward appears posteriorly, 
which is called the caudal or tail fold. Laterally folds also arise. 
These folds all tend to grow toward the centre of the under surface of 
what will be the embryo. 

The mesoblastic layer of the blastoderm, except that part which forms 
the axis of the embryo, splits into an upper layer, the somato-pleure, 
which is beneath the epiblast, and a lower layer, the splanehno-pleure, 
which lies upon the hypoblast. The space formed by this cleavage of 
the mesoblast is called the pleuro-peritoneal cavity. The somato-pleure 
is engaged in the formation of the body walls of the embryo. The 
splanehno-pleure forms the walls of the alimentary tract. 

Formation of the Amnion. — Processes arise from the somato-pleure 
anteriorly, posteriorly, and laterally, which gradually arch over the 

dorsal surface of the foetus until they 
meet each other and form a complete 
envelope to it. At the ventral surface 
these processes are separated by the 
Avhole length of the embryo, but they 
here also gradually approach each 
other, and eventually surround what 
is subsequently the umbilical cord, 
and blend Avith the integument of 
the foetus at the point of its inser- 
tion. In this way is formed the am- 
nion (Fig. 55), consisting of two 
layers : the internal, derived from the 
epiblast, is formed of tessellated epi- 
thelial cells; the external, arising from 
the mesoblast, is formed of cells like 
those of young connective tissue. Be- 
fore the folds of the amnion unite, the 
free edge of each is bent outward and 
spreads around the ovum, immediately within the zona pellucida, form- 
ing a lining to it, termed by Turner the subzonal membrane, which is 
connected with the development of the chorion. The amnion is the 
most internal of the membranes surrounding the foetus, and will pres- 
ently be studied more in detail. It soon becomes distended with fluid, 
the liquor amnii, and as this increases in amount it separates the amnion 
more and more from the foetus. 

Changes in the Hypoblast. — During this time the innermost layer of 
the blastodermic membrane or hypoblast is also developing two pro- 
jections at either extremity of the foetus, and these gradually approach 
each other anteriorly. As the hypoblast is in contact with the yelk, when 
these meet they have the effect of dividing the yelk into two portions. 
One, and the smaller of the two, forms eventually the intestinal canal 
of the foetus ; the other, and much the larger, contains the greater por- 




ter of 



Development of the Amnion 
1. Vitelline membrane. 2. External lay 
blastodermic membrane. 3. Internal layers 
forming the umbilical vesicle. 4. Umbilical 
vessels. 5. Projections forming amnions. 
6. Embryo. 7. Allantois. 



CONCEPTION AND GENERATION 



107 



tion of the yelk, and forms the ephemeral structure known as the umbili- 
cal vesicle, from which the foetus derives most of its nourishment during 
the early stage of its existence. Its communication with the abdominal 
cavity of the foetus is through the constricted portion at the point of 

Fig. 56. 




1. Exo-chorion. 2. External layer of blastodermic membrane. 3. Umbilical Tesicle. 4. Its vessels. 
5. Amnion. 6. Embryo. 7. Allantois increasing in size. 



Fig. 



division called the vitelline duct (Fig. 56). An artery and vein, the 
omphalo-mesentericy ramify on the vesicle and its duct. 

As the amnion increases in size, it pushes back the umbilical vesicle 
toward the external membrane of the ovum, between which and the 
amnion it lies (Fig. 57) ; and when the allantois is developed, it ceases 
to be of any use, and rapidly shrinks and dwindles away. In most 
mammals no trace of it can be found after the fourth month of utero- 
gestation ; in some, including the human female, it 
is said to exist as a minute vesicle at the placental 
end of the umbilical cord at the full period of preg- 
nancy. The umbilical vesicle is filled with a yel- 
lowish fluid, containing many oil- and fat-globules, 
similar to the yelk of an egg. 

The Allantois. — Somewhere about the twentieth 
day after conception a small vesicle is formed toward 
the caudal extremity of the foetus, which is called 
the allantyis. This membrane in mammals is im- 
portant, as it forms the greater part of the fetal 
placenta, a small portion of it remaining inside the 
body permanently as the bladder. It begins as a 
diverticulum from the lower part of the intestinal 
canal. This, at first spherical, rapidly develops and 
becomes pyriform in shape, while, by a process of 
constriction similar to that which occurs in the vitel- 
lus to form the umbilical vesicle, it becomes divided into two parts 
municating with each other, the smaller of them being eventually 
developed into the urinary bladder. The larger portion, leaving (he 
abdominal cavity along with the vitelline duct, rapid 




An Embryo of about 
twenty-live days laid 

open. ' i After Coste.) 
a. Chorion. /•. Amnion. 
<•. Cavity of chorion. 
<l. Umbilical vesicle. 
<■. Pedicle of allantois. 
/. Embryo. 



coin- 



grows until 



il 



108 PREGNANCY. 

comes into contact with the most external ovular membrane, the chorion, 
over the entire inner surface of which it spreads. In this part vessels 
soon develop — namely, the two umbilical arteries, derived from the 
abdominal aorta, and two umbilical veins, one of which subsequently 
disappears ; these, along with the vitelline duct and the pedicle of the 
allantois, form the umbilical cord. The main and very important func- 
tion of the allantois, therefore, is to carry the foetal vessels up to the 
inner surface of the subzonal membrane. Besides this purpose, the allan- 
tois, at a very early period, may receive the excretions of the foetus and 

Fig. 58. 




1. Exo-chorion. 2. External layer of the blastodermic membrane. 3. Allantois. 4. Umbilical vesicle. 
5. Amnion. G. Embryo. 7. Pedicle of allantois. 

serve as an excrementitious organ. According to Cazeaux, scarcely a 
trace of the allantois can be seen a few days after its formation. Its 
lower part or pedicle, however, long remains distinct, and forms part of 
the umbilical cord ; and traces of it may be found even in adult life in 
the form of the urachus, which is really the dwindled pedicle and forms 
one of the ligaments of the bladder. 

The Corps Reticule or Vitriform Body. — Between the chorion and 
amnion is often found a gelatinous fluid, with minute filamentous pro- 
cesses traversing it, called by Velpeau the corps reticule, which is not met 
with until the allantois comes into contact with the chorion, and Avhich 
seems to be formed out of the tissues of that vesicle. It is analogous 
to the so-called Wharton's jelly found in the umbilical cord. When 
first formed it is highly vascular, but the vessels entirely disappear after 
the placenta is formed, and the remainder of the chorionic villi atrophy. 
Sometimes it exists in considerable quantities, and should the chorion 
rupture at the end of pregnancy it may escape and give rise to an errone- 
ous impression that the liquor amnii has been discharged. 

Recapitulation. — Before proceeding to consider the foetal envelopes 
more at length, it may be useful to recapitulate the structures already 
alluded to as forming the ovum. In this we find — 

1. The embryo itself. 

2. A fluid, the liquor amnii, in which it floats. 



CONCEPTION AND GENERATION. 109 

3. The amnion, a purely foetal membrane surrounding the embryo, 
and containing the liquor amnii. 

4. The umbilical vesicle, containing the greater portion of the yelk, 
serving as a source of nutrition to the early embryo through the vitelline 
duct, and on which ramify the omphalo-mesenteric vessels. 

5. The allantois, a vesicle proceeding from the caudal extremity of the 
embryo, spreading itself over the interior of the ovum, and serving as a 
channel of vascular communication between the chorion and the foetus 
through the umbilical vessels. 

6. An interspace between the outer layer of the ovum and the amnion, 
in which is contained the umbilical vesicle and allantois and the corps reti- 
cule of Velpeau. 

7. The outer layer of the ovum, along with the subzonal membrane, 
forming the chorion and placenta. 

The Amnion. — The amnion is the most internal of the two membranes 
surrounding the foetus; its origin at an early period of foetal life has 
already been described. It is a perfectly smooth, transparent, but tough 
membrane, continuous with the integument of the foetus at the insertion 
of the umbilical cord, round which it forms a sheath. Soon after it is 
formed it becomes distended with a fluid, the liquor amnii, in which the 
foetus is suspended and floats. This fluid increases gradually in quantity, 
distending the amnion as it does so, until this is brought into contact 
with the inner surface of the chorion, from which it was at first sepa- 
rated by a considerable interspace. 

Structure of the Amnion. — The internal surface of the amnion is 
smooth and glistening, and on microscopic examination it is found to 
consist of a layer of flattened cells, each containing a large nucleus. 
These rest on a stratum of fibrous tissue which gives to the membrane 
its toughness, and by which it is attached to the inner surface of the 
chorion. It is entirely destitute of vessels, nerves, and lymphatics. 

The Liquor Amnii. — The quantity of the liquor amnii varies much at 
different periods of pregnancy. In the early months it is relatively 
greater in amount than the foetus, which it outweighs. As pregnancy 
advances, the weight of the foetus becomes four or five times greater than 
that of the liquor amnii, although the actual quantity of fluid increases 
during the whole period of gestation. The amount of fluid varies much 
in different pregnancies. Sometimes there is comparatively little, while at 
others the quantity is immense, reaching several pounds in weight, greatly 
distending the uterus, and thus, it may be, producing difficulty in labor. 

Its Quality. — At first the liquid is clear and limpid. As pregnancy 
advances it becomes more turbid and dense, from the admixture of 
epithelial debris derived from the cutaneous surface of the foetus. In 
some cases, without actual disease, it may be dark green in color and 
thick and tenacious in consistency. It has a peculiar heavy odor, and 
it consists chemically of water containing albumen, with various salts, 
principally phosphates and chlorides. 

Its Source. — The source of the liquor amnii has been much disputed. 
Some maintain that it is derived chiefly from the foetus — a view suffi- 
ciently disproved by the fact that the liquor amnii continues to increase 
in amount after the death of the foetus. Burdach believed that it is 



110 PREGNANCY. 

secreted by the internal surface of the uterus, and arrives in the cavity 
of the amnion by transudation through the membrane. Priestley — and 
this seems the most probable hypothesis — thinks that it is secreted by 
the epithelial cells lining the membrane, which become distended with 
fluid, burst, and pour their contents into the amniotic cavity. 

Functions and Uses. — The most obvious use of the liquor amnii is to 
afford a fluid medium in which the foetus floats, and so is protected from 
the shocks and jars to which it would otherwise be subjected, and from 
undue pressure upon the uterine walls. By distending the uterus it 
saves the uterus from injury, which the movements of the foetus might 
otherwise inflict, and the foetus is thus also enabled to change its position 
freely. The facility with which version by external manipulation can 
be effected depends entirely on the mobility of the foetus in the fluid 
which surrounds it. Some have also supposed that it prevents the 
foetus, in the early months of pregnancy, from forming adhesions to the 
amnion. In labor it is of great service by lubricating the passages, but 
chiefly by forming, with the membranes, a fluid wedge which dilates the 
circle of the os uteri. 

The Chorion. — The chorion is the more external of the truly foetal 
membranes, although external to it is the decidua, having a strictly 
maternal origin. It is a perfectly closed sac, its external surface, in 
contact with the decidua, being rough and shaggy from the development 
of villi (Fig. 56), its internal smooth and shining. As the ovum passes 
along the Fallopian tube it receives, as we have seen, an albuminous 
coating, and this, with the zona pellucida, is developed into a temporary 
structure, the primitive chorion. On its external surface villous promi- 
nences soon appear, which have no ascertained structure, and which 
seem to supply the early ovum with nutriment by endosmotic absorp- 
tion from the mucous membrane of the uterus. This primitive chorion, 
however, has not been observed in the human subject, although it may 
be readily seen in the ova of some of the lower animals, such as the 
clog and the rabbit. Some twelve days after conception, when the 
blastodermic membrane is formed, the true chorion appears. This is, 
in fact, formed by the epiblast layer of the blastodermic membrane, 
which everywhere lines the zona pellucida or primitive chorion, and, 
by pressure, causes its absorption and disappearance. On the surface 
of the true chorion thus formed, which is now the external envelope 
of the ovum, villi soon appear. 

Formation of the Villi. — These villi are hollow projections like the 
fingers of a glove, which are raised up from the surface of the chorion 
(the hollows looking into the chorionic cavity), and they cover the 
whole external surface of the ovum, giving it the peculiar shaggy 
appearance observed in early abortions. They push themselves into 
the substance of the decidua, with which they soon become so firmly 
united that they cannot be separated without laceration. At first they 
are absolutely non-vascular, but soon the allantois, previously described, 
reaches the inner surface of the chorion and spreads itself over the 
whole of it. Each villus now receives a separate artery and vein, the 
former having a branch to each of the subdivisions into which the villus 
divides. These vessels are encased in a fine sheath of the allantois, 



CONCEPTION AND GENERATION. Ill 

which enters the villus along with them and forms a lining to it, de- 
scribed by some as the endo-chorion, the external epithelial membrane 
of the villus, derived from the epiblast layer of the blastodermic mem- 
brane, being called the exo-chorion. The artery and vein lie side by 
side in the centre of the villus and anastomose at its extremity ; each 
villus thus having a separate circulation. 

Growth and Atrophy of the Villi. — As soon as the union of the 
allantois with the chorion has been effected, the villi grow very rapidly, 
give off branches, which in their turn give off secondary branches, and 
so form root-like processes of great complexity. In the early months 
of gestation they exist equally over the whole surface of the ovum. 
As pregnancy advances, however, those which are in contact with the 
decidua reflexa shrivel up, and by the end of the second month dis- 
appear, being no longer required for the nutrition of the ovum. The 
chorion and decidua thus come into close contact, being united together 
by fibrous shreds, which on microscopic examination are found to consist 
of atrophied villi. A certain number of villi — viz., those which are in 
contact with the decidua serotina — instead of dwindling away, increase 
greatly in size, and eventually develop into the organ by which the 
foetus is nourished — the placenta. 

Form of the Placenta. — This important organ serves the purpose of 
supplying nutriment to, and aerating the blood of, the foetus, and on its 
integrity the existence of the foetus depends. It is met with in all 
mammals, but is very different in form and arrangement in different 
classes. Thus, in the sow, mare, and in the cetacea it is diffused over 
the whole interior of the uterus ; in the ruminants it is divided into a 
number of separate small masses, scattered here and there over the 
uterine walls ; while in the carnivora and elephant it forms a zone or 
belt round the uterine cavity. In the human race, as well as in roclentia, 
insectivora, etc., the placenta is in the form of a circular mass, attached 
generally to some part of the uterus near the orifices of one Fallopian 
tube ; but it may be situated anywhere in the uterine cavity, even over 
the internal os uteri. As it is expelled after delivery with the foetal 
membranes attached to it, and as the aperture in these corresponds to 
the os uteri, we can generally determine pretty accurately the situation 
in which the placenta was placed by examining them after expulsion. 
The maternal surface of the placenta is somewhat convex, the foetal 
concave. Its size varies greatly in different cases, and it is usually 
largest when the child is big, but not necessarily so. Its average 
diameter is from 6 to 8 inches, its weight from 18 to 24 oz., but in 
exceptional cases it has been found to weigh several pounds. A 1 (nor- 
malities of form are not very rare. Thus, the placenta has been found 
to be divided into distinct parts — a form said by Professor Turner to 
be normal in certain genera of monkeys; or smaller supplementary 
placentae (placentce succentarice) may exist round a central mass. These 
variations of shape are only of importance in consequence of a risk of 
part of the detached placenta being left in the uterus after delivery and 
giving rise to septicaemia or secondary haemorrhage. 

Attachment of the Membranes. — The foetal membranes cover the whole 
foetal surface of the placenta, being reflected from its edges so as to line 



112 PREGNANCY. 

the uterine cavity, and being expelled with it after delivery* They also 
leave it at the insertion of the cord, to which they form a sheath. The 
cord is generally attached near the centre of the placenta, and from its 
insertion the umbilical vessels may be seen dividing and radiating over 
the whole fetal surface. 

Its Maternal Surface. — The maternal surface is rough and divided by 
numerous sulci, which are best seen if the placenta is rendered convex, 
so as to resemble its condition when attached to the uterus. A careful 
examination shows that a delicate membrane covers the entire maternal 
surface, unites the sulci together, and dips down between them. This 
is, in fact, the cellular layer of the decidua serotina, which is separated 
and expelled with the placenta, the deeper layer remaining attached to 
the uterus. Numerous small openings may be seen on the surface, 
which are the apertures of the veins torn oif from the uterus, as also 
those of some arteries, which, after taking several sharp turns, open 
suddenly into the substance of the organ. 

Minute Structure of the Placenta. — As regards the minute structure 
of the placenta, it is certain that it consists essentially of two distinct 
portions — one foetal, consisting of the greatly hypertrophied chorion 
villi, with their contained vessels, which carry the foetal blood so as to 
bring it into intimate relation with the maternal blood, and thus admit 
of the necessary changes occurring in it connected with the nutrition of 
the foetus ; and the other maternal, formed out of the decidua serotina 
and the maternal blood-vessels. These two portions are in the human 
female so intimately blended as to form the single deciduous organ 
which is thrown oif after delivery. These main facts are admitted by 
all, but considerable differences of opinion still exist among anatomists 
as to the precise arrangement of these parts. In the following sketch 
of the subject I shall describe the views most generally entertained, 
merely briefly indicating the points which are contested by various 
authorities. 

Festal Portion of the Placenta. — The foetal portion of the placenta 
consists essentially of the ultimate ramifications of the chorion villi, 
which may be seen on microscopic examination in the form of club- 
shaped digitations, which are given oif at every possible angle from the 
stem of a parent trunk, just like the branches of a plant. Within the 
transparent walls of the villi the capillary tubes of the contained vessels 
may be seen lying, distended with blood, and presenting an appearance 
not unlike loops of small intestine. The capillaries are the terminal 
ramifications of the umbilical arteries and veins, which, after reaching 
the site of the placenta, divide and subdivide until they at last form an 
immense number of minute capillary vessels, with their convexities look- 
ing toward the maternal portion of the placenta, each terminal loop 
being contained in one of the digitations of the chorion villi. Each 
arterial twig is accompanied by a corresponding venous branch, which 
unites with it to form the terminal arch or loop (Fig. 59). The foetal 
blood is carried through these arterial twigs to the villi, where it comes 
into intimate contact with the maternal blood, in consequence of the 
anatomical arrangements presently to be described ; but the two do not 
directly mix, as the older physiologists believed, for none of the mater- 



CONCEPTION AND GENERATION. 



113 



nal blood escapes when the umbilical cord is cut, nor can the minutest 
injections through the foetal vessels be made to pass into the maternal 




Placental Villus, greatly magnified. (After Joulin.) 

1, 2, Placental vessels, forming terminal loops. 3. Chorion tissue, forming external -walls of villus. 

4. Tissue surrounding vessels. 

vascular system, or vice versa. In addition to the looped terminations of 
the umbilical vessels, Farre and Schroeder van der Kolk have described 

Fig. 60. 




a. Terminal villus of foetal tuft, minutely injected, b. Its nucleated non-vascular sheath. (After Farre.) 

another set of capillary vessels in connection with each villus (Fig. HO). 
This consists of a very fine network covering each villus, and very differ- 



114 PREGNANCY. 

ent in appearance from the convoluted vessels lying in its interior, which 
are the only ones which have been usually described. Dr. Farre believes 
that these vessels only exist in the early months of pregnancy, and that 
they disappear as pregnancy advances. Priestley l suggests that they may 
not be vessels at all, but lymphatics, which may possibly absorb nutrient 
material from the mother's blood and throw it into the foetal vascular 
system. The existence of lymphatics, or nerves, in the placenta, how- 
ever, has never been demonstrated, and they are believed not to exist. 

Maternal Portion of the Placenta. — As generally described, the mater- 
nal portion of the placenta consists of large cavities, or of a single large 
cavity, which contains the maternal blood, and into which the villi of 
the chorion penetrate (Fig. 61). Into this maternal part of the viscus 
the curling arteries of the uterus pour their blood, which is collected 
from it by the uterine sinuses. The villi of the chorion, therefore, are 

Fig. 61. 




Diagram representing a Vertical Section of the Placenta. (After Dalton.) 
«, a. Chorion, b, b. Decidna. c, c, c, c. Orifices of uterine sinuses. 

suspended in a sac filled with maternal blood, which penetrates freely 
between them, and with which they are brought into very intimate con- 
tact. 

Theory of Reid. — Dr. John Reicl believed that only the delicate inter- 
nal lining of the maternal vessels entered the substance of the placenta 
to form the sac just spoken of. Into this the villi project, pushing 
before them the membrane forming the limiting wall of the placental 
sinuses, each of them in this way receiving an investment, just as the 
fingers of a hand are covered by a glove (Fig. 62). 

Theory of Goodsir. — Schroeder van der Kolk and Goodsir (Fig. 63) 
were of opinion that not only were the maternal blood-vessels continued 
into the substance of the placenta, but also the processes of the decidua, 
which accompanied the vessels and were prolonged over each villus, so 
as to separate it from the limiting membrane of the maternal sinuses. 

1 The Gravid Uterus, p. 52. 



CONCEPTION AND GENERATION. 



115 



Each villus would thus be covered by two layers of fine tissue — one 
from the internal lining membrane of the maternal blood-vessels, the 
other from the epithelial cells of the decidua. 

Theory of Turner. — Turner, whose valuable researches on the com- 
parative anatomy of the placenta have thrown much light on its struc- 
ture, points out that the placentae of all animals are formed on the same 



Fig. 62. 



Fig. 63. 



C— ^ 





Diagram illustrating the mode in which a Placen- 
tal Villus derives a Covering from the Vascular 
System of the Mother. (After Priestley.) 

a. "Villus having three terminal digitations projecting into 
b. Cavity of the mother's vessel, c. Dotted lines repre- 
senting coat of vessel. 



The Extremity of a Placental Villus. 
(After Goodsir.) 

a. External membrane of villus Cthe lining 
membrane of vascular system of Weber). 

b. External cells of villus derived from 
decidua. 

c. c. Nuclei of ditto. 

d. The space between the maternal and 
foetal portions of villus. 

e. Its internal membrane. 
/. Its internal cells. 

g. The loop of umbilical vessels. 



fundamental type/ in which the foetal portion consists of a smooth, plane- 
surfaced vascular membrane covered with pavement epithelium, which 
is brought into contact with the maternal portion, consisting of a smooth, 
plane-surfaced vascular membrane covered with columnar epithelium. 
The foetal capillaries are separated from the maternal capillaries only by 
two opposed layers of epithelium. In various animals the placentae are 
more or less specialized from the generalized form, in some to a much 
greater extent than others. In the human placenta the maternal vessels 
have lost their normal cylindrical form, and are dilated into a system of 
freely intercommunicating placental sinuses, which are, in fact, maternal 
capillaries enormously enlarged, with their walls so expanded and thinned 
out that they cannot be recognized as a distinct layer limiting the sinus. 
Each foetal chorion villus projecting into these sinuses is covered with a 
layer of cells distinct from those of the epithelial layer of the villus, 
and readily stripped from it. These are maternal in their origin, and 
are derived from the decidua, which sends prolongations of its tissue 
into the placenta. These cells, he believes, form a secreting epithelium 
which separates from the maternal blood a secretion for the nourishment 
of the fetus, which is, in its turn, absorbed by the villi of the chorion. 
Theory of Ftrcolani. — A view not very dissimilar to this has been 
advanced by Professor Ercolani of Bologna, who maintains that the 
maternal portion of the placenta is a new formation, strictly glandular, 
and not vascular, in its structure. It is formed, he thinks, by the sub- 
mucous connective tissue of the decidua serotina, and it dips down into 
the placenta and forms a sheath to each of the chorion villi, which it 

1 Introduction to Human Anatomy, Part 2. 



116 PREGNANCY. 

separates from the maternal blood. This new glandular structure he 
describes as secreting a fluid, termed the " uterine milk," which is ab- 
sorbed by the villi of the chorion, just as the mother's milk is absorbed 
by the villi of the intestines, and it is with this fluid alone that the 
chorion villi are in direct contact. The sheath thus formed to each villus 
is doubtless analogous to the layer of cells which Goodsir described as 
encasing each villus, but is attributed to a new structure formed after 
conception. 

Theory of Braxton Hicks. — The existence of the maternal sinus sys- 
tem in the placenta is altogether denied by anatomists of eminence whose 
views are worthy of careful consideration. Prominent among these is 
Braxton Hicks, 1 who has written an elaborate paper on the subject. He 
holds that there is no evidence to prove that the maternal blood is poured 
out into a cavity in which the chorion villi float, and he believes that 
the curling arteries, instead of entering the so-called maternal portion 
of the placenta, terminate in the decidua serotina. The hypertrophied 
chorion villi at the site of the placenta are firmly attached to the decidual 
surface, into which their tips are imbedded. The line of junction be- 
tween the decidual reflexa and serotina forms a circumferential margin 
to, and limits, the placenta. The arrangement of the foetal portion of 
the placenta on this view is very similar to that generally described, but 
the villi are not surrounded by maternal blood at all, and nothing exists 
between them, unless it be a small quantity of serous fluid. The change 
in the foetal blood is effected by enclosmosis, and Hicks suggests that the 
follicles of the decidua may secrete a fluid, which is poured into the 
intervillous spaces for absorption by the villi. 

Functions of the Placenta. — It will thus be seen that anatomists of 
repute are still undecided as to important points in the minute anatomy 
of the placenta, which further investigation will doubtless clear up. 
The main functions of the organ are, however, sufficiently clear. During 
the entire period of its existence it fills the important office of both 
stomach and lungs to the foetus. Whatever view of the arrangement 
of the maternal blood-vessels be taken, it is certain that the foetal blood 
is propelled by the pulsations of the foetal heart into the numberless villi 
of the chorion, where it is brought into very intimate relation with the 
mother's blood, gives off its carbonic acid, absorbs oxygen, and passes 
back to the foetus, through the umbilical vein, in a fit state for circula- 
tion. The mode of respiration, therefore, in the foetus is analogous to 
that in fishes, the chorion villi representing the gills, the maternal blood 
the water in which they float. Nutrition is also effected in the organ, 
and, by absorption through the chorion villi, the pabulum for the 
nourishment of the foetus is taken up. It also probably serves as an 
emunctory for the products of excretion in the foetus. Picard found 
that the blood in the placenta contained an appreciably larger quantity 
of urea than that in other parts of the body, this urea probably being 
derived from the foetus. Claude Bernard also attributed to it a glyco- 
genic function, 2 supposing it to take the place of the foetal liver until 
that organ was sufficiently developed. 

Jhyenerative Changes Previous to Expulsion. — Finally, we find that 

1 Obst. Trans., vol. xiv. 2 Acad, des Sciences, April, 1859. 



COXCEPTIOX AXD GENERATION. 117 

the temporary character of the placenta is indicated by certain degenera- 
tive changes which take place in it previous to expulsion. These consist 
chiefly in the deposit of calcareous patches on its uterine surface, and in 
fatty degeneration of the villi and of the decidual layer between the 
placenta and the uterus. If this degeneration be carried to excess, as is 
not unfrequently the case, the foetus may perish from want of a sufficient* 
number of healthy villi through which its respiration and nutrition may 
be effected. 

Umbilical Cord. — The umbilical cord is the channel of communication 
between the foetus and placenta, being attached to the former at the um- 
bilicus, to the latter generally near its centre, but sometimes, as in the 
battledore placenta, at its edge. It varies much in length, measuring 
on an average from 18 to 24 inches, but in exceptional cases being found 
as long as 50 or 60, and as short as 5 or 6, inches. 

When fully formed it consists of an external membranous layer formed 
of the amnion, two umbilical arteries, one umbilical vein, and a con- 
siderable quantity of a transparent gelatinous substance surrounding the 
vessels, called Wharton's jelly, which is contained in a fine network of 
fibres, and is formed out of the tissue of the allantois. At an early 
period of pregnancy, in addition to these structures, the cord contains 
the pedicle of the umbilical vesicle, with the omphalo-mesenteric vessels 
ramifying on it, and two umbilical veins, one of which soon atrophies 
and disappears. Xo nerves or lymphatics have been satisfactorily demon- 
strated in the cord, although such have been described as existing. The 
vessels of the cord are at first straight in their course, but shortly they 
become greatly twisted, the arteries being external to the vein, and in 
nine cases out of ten the twist is from left to right. Various explana- 
tions have been given of this peculiarity, none of them entirely satis- 
factory. Tyler Smith attributed it to the movements of the foetus 
twisting the cord, its attachment to the placenta being a fixed point ; 
this would not, however, account for the frequency with which the 
spiral turns occur in one direction. Mr. John Simpson attributed it to 
the greater pressure of the blood through the right hypogastric artery, 
on account of that vessel having a more direct relation to the aorta than 
the left. The umbilical arteries give off no branches, and the vein con- 
tains no valves, nor can any vasa vasoram be detected in their coats 
after they have left the umbilicus. The umbilical arteries increase in 
size after they leave the cord to divide on the surface of the placenta. 
This is the only example in the body in which arteries arc larger near 
their terminations than their origin, and the object of this arrangement 
is probably to effect a retardation of the current of the blood distrib- 
uted to the placenta. The tortuous course of the vein probably com- 
pensates for the absence of valves, and moderates the flow of blood 
through it. Distinct knots are not unfrequently observed in the cord, 
but they rarely have the effect of obstructing the circulation through it. 
They no doubt form when the foetus i- very small. They may some- 
times also be produced in labor by the child being propelled through a 
coil of the cord lying circularly round the os uteri. The so-called false 
knots are merely accidental nodosities due to local enlargements of the 
vessels. 



118 PREGNANCY. 



CHAPTER II, 

THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 

It is obviously impossible to attempt anything like a full account of 
the development of the various fetal structures, or of their growth, dur- 
ing intra-uterine life. To do so would lead us far beyond the scope of 
this work, and would involve a study of complex details only suitable 
in a treatise on embryology. It is of importance, however, that the 
practitioner should have it in his power to determine approximately the 
age of the foetus in abortions or premature labors, and for this purpose 
it is necessary to describe briefly the appearance of the foetus at various 
stages of its growth. 

Appearance of the Foetus at Various Stages of Development. — 1st 
Month : The foetus in the first month of gestation is a minute gelatinous 
and semi-transparent mass, of a grayish color, in w r hich no definite 
structure can be made out, and in which no head or extremities can be 
seen. It is rarely to be detected in abortions, being lost in surrounding 
blood-clots. In the few examples which have been carefully examined 
it did not measure more than a line in length. It is, however, already 
surrounded by the amnion, and the pedicle of the umbilical vesicle can 
be traced into the unclosed abdominal cavity. 

2d Month : The embryo becomes more distinctly apparent, and is 
curved on itself, weighing about 62 grains, and measuring 6 to 8 lines 
in length. The head and extremities are distinctly visible, the latter in 
the form of rudimentary projections from the body. The eyes are to be 
seen as small black spots on the side of the head. The spinal column is 
divided into separate vertebrae. The independent circulatory system of 
the foetus is now beginning to form, the heart consisting of only one 
ventricle and one auricle, from the former of which both the aorta and 
pulmonary arteries arise. On either side of the vertebral column, reach- 
ing from the heart to the pelvis, are two large glandular structures, the 
eorpora Wolfflana, which consist of a series of convoluted tubes open- 
ing into an excretory duct running along their external borders, and 
connected below with the common cloaca of the genito-urinary and 
digestive tracts. They seem to act as secreting glands, and fulfil the 
functions of the kidneys before they are formed. Toward the end of the 
second month they atrophy and disappear, and the only trace of them in 
the foetus at term is to be found in the parovarium lying between the 
folds of the broad ligaments. At this stage of development there are 
met with in the human embryo, as in that of all mammals, four trans- 
verse fissures opening into the pharynx, which are analogous to the per- 
manent branchiae of fishes. Their vascular supply is also similar, as the 
aorta at this time gives off four branches on each side, each of which 
forms a branchial arch, and these afterward unite to form the descend- 
ing aorta. By the end of the sixth week these, as well as the transverse 



THE AX ATOMY AND PHYSIOLOGY OF THE FCETUS. 119 

fissures to which they are distributed, disappear. By the end of the 
second month the kidneys and supra-renal capsules are forming, and the 
single ventricle is divided into two by the growth of the inter- ventric- 
ular septum. The umbilical cord is quite straight, and is inserted into 
the lower part of the abdomen. Centres of ossification are showing 
themselves in the inferior maxillary bones and the clavicle. 

3d Month : The embryo weighs from 70 to 300 grains, and measures 
from 1\ to Z\ inches in length. The forearm is well formed, and the 
first traces of the fingers can be made out. The head is large in propor- 
tion to the rest of the body, and the eyes are prominent. The umbilical 
vesicle and allantois have disappeared, the greater portion of the chorion 
villi have atrophied, and the placenta is distinctly formed. 

4th Month : The weight is from 4 to 6 oz., and the length about 6 
inches. The convolutions of the brain are beginning to develop. The 
sex of the child can now be ascertained on inspection. The muscles are 
sufficiently formed to produce distinct movements of the limbs. Ossifi- 
cation is extending, and can be traced in the occipital and frontal bones 
and in the mastoid processes. The sexual organs are differentiated. 

5th Month : Weight, about 10 oz. ; length, 9 or 10 inches. Hair is 
observed covering the head, which forms about one-third of the length 
of the whole foetus. The nails are beginning to form, and ossification 
has commenced in the ischium. 

6th Month: Weight, about 1 lb.; length, 11 to 12| inches. The 
hair is darker. The eyelids are closed, and the membrana pupillaris 
exists ; eyelashes have now been formed. Some fat is deposited under 
the skin. The testicles are still in the abdominal cavity. The clitoris 
is prominent. The pubic bones have begun to ossify. 

7th Month : Weight, from 3 to 4 lbs. ; length, 13 to 15 inches. The 
skin is covered with unctuous, sebaceous matter, and there is a more 
considerable deposit of subcutaneous fat. The eyelids are open. The 
testicles have descended into the scrotum. 

8th Month : Weight, from 4 to 5 lbs. ; length, 16 to 18 inches, and 
the fetus seems now to grow in thickness rather than in length. The 
nails are completely developed. The membrana pupillaris has disap- 
peared. 

Foetus at Term. — At the completion of pregnancy the foetus weighs on 
an average 6^ lbs. and measures about 20 inches in length. These 
averages are, however, liable to great variation. Remarkable histories 
arc given by many writers of foetuses of extraordinary weight, which 
have been probably greatly exaggerated. Out of 3000 children deliv- 
ered under the care of Cazeaux at various charities, one only weighed 10 
lbs. There are, however, several carefully recorded instances of weight 
far exceeding this, but they are undoubtedly much more uncommon 
than is generally supposed. Dr. Ramsbottom mention- a foetus weigh- 
ing 16| lbs.; Cazeaux tell- us of one which he delivered by turning 
which weighed 18 lbs. and measured 2 feet 1 \ inches, and the birth of 
one weighing 21 lbs. has been recentlv 
dren are almost invariably stillborn. ['] 

1 Brit. Med. Journ., Feb. 1. 1879. 

[ 2 Probably the largest foetus on record was thai of Mrs. Captain Bates, the Nova 



120 PREGNANCY. 

The average size of male children at birth, as in after-life, is some- 
what greater than that of female. Thus, Simpson 1 found that out of 100 
cases the male children averaged 10 oz. more in weight than the female, 
and half an inch more in length. 

Vernix Caseosa. — A new-born child at term is generally covered to a 
greater or less extent with a greasy, unctuous material, the vernix 
caseosa, which is formed of epithelial scales and the secretion of the 
sebaceous glands, and which is said to be of use in labor by lubricating 
the surface of the child. The head is generally covered with long dark 
hair, which frequently falls oif or changes in color shortly after birth. 
Dr. Wiltshire 2 has called attention to an old observation, that the eyes 
of all new-born children are of a peculiar dark steel-gray color, and 
that they do not acquire their permanent tint until some time after 
birth. The umbilical cord is generally inserted below the centre of the 
body. 

Anatomy of the Foetal Head. — The most important part of the foetus 
from an obstetrical point of view is the head, which requires a separate 
study, as it is the usual presenting part, and the facility of the labor 
depends on its accurate adaptation to the maternal passages. 

The chief anatomical peculiarity of interest in the head of the foetus at 
term is that the bones of the skull, especially of its vertex — which, in 
the vast majority of cases, has to pass first through the pelvis — are not 
firmly ossified as in adult life, but are joined loosely together by mem- 
brane or cartilage. The result of this is, that the skull is capable of 
being moulded and altered in form to a very considerable extent by the 
pressure to which it is subjected, and thus its passage through the pelvis 
is very greatly facilitated. This, however, is chiefly the case with the 
cranium proper, the bones of the face and of the base of the skull being 
more firmly united. By this means the delicate structures at the base 
of the brain are protected from pressure, while the change of form which 
the skull undergoes during labor implicates a portion of the skull where 
pressure on the cranial contents is least likely to be injurious. 

The divisions between the bones of the cranium are further of obstet- 
ric importance in enabling us to detect the precise position of the head 
during labor, and an accurate knowledge of them is therefore essential to 
the obstetrician. 

The Sutures and Fontanelles. — We talk of them as sutures and fonta- 
nelles, the former being the lines of junction between the separate bones, 
which overlap each other to a greater or less extent during labor ; the 
latter, membranous interspaces where the sutures join each other. 

The principal sutures are : 1st, the sagittal, which separates the two 
parietal bones, and extends longitudinally backward along the vertex 

Scotia giantess, a woman of 7 ft. 9 in., whose husband is also of gigantic build, reaching 
7 ft. 7 in. in height This child, born in Ohio, was their second, and was lost in its 
birth, as no forceps could be procured of sufficient size to grasp the head. The foetus 
weighed 23| lbs. and was 30 in. in length. Their first infant weighed 18 lbs. Dr. 
George Eddowes of Crewe, England, delivered a woman, on Nov. 12, 1884, of a male 
child weighing 20 lbs. 2 oz. It matured 23 inches in length and 14.} inches around 
the chest (Lancet, Nov. 22, 1884, p. 941). We have had children born in this city 
(Philadelphia) at maturity and live that weighed but one pound. The well-remem- 
bered "Pincus baby" weighed a pound and an ounce. — Ed.] 

1 Selected Obst. Works, p. 327. 2 Lancet, February 11, 1871. 



THE AX ATOMY AST) PHYSIOLOGY OF THE FCETUS. 



121 



of the head ; 2d, the frontal, which is a continuation of the sagittal, 
and divides the two halves of the frontal bone, at this time separate 
from each other ; 3d, the coronal, which separates the frontal from the 
parietal bones, and extends from the squamous portion of the temporal 
bone across the head to a corresponding point on the opposite side ; and 
4th, the lambdoidal, which receives its name from its resemblance to the 
Greek letter A, and separates the occipital from the parietal bones on 
either side. The fontanelles (Fig. 64) are the membranous interspaces 
where the sutures join — the anterior and larger being lozenge-shaped, 
and formed by the junction of the frontal, sagittal, and two halves of the 
coronal sutures. It will be well to note that there are, therefore, four 
lines of sutures running into it, and four angles, of which the anterior, 
formed by the frontal suture, is most elongated and well marked. The 
posterior fontanelle (Fig. 65) is formed by the junction of the sagittal 
suture with the two legs of the lambdoidal. It is therefore triangular 
in shape, with three lines of suture entering it in three angles, and is 



Fig. 64. 




Fig. 




Anterior and Posterior 
Fontanelles. 



Bi-parietal Diameter. Sagittal and Lambdoidal 
Sutures, with Posterior Fontanelle. 



much smaller than the anterior fontanelle, forming merely a depression 
into which the tip of the finger can be placed, while the latter is a hollow 
as big as a shilling, or even larger. As it is the posterior fontanelle 
which is generally lowest, and the one most commonly felt during labor, 
it Is important for the student to familiarize himself with it, and he 
should lose no opportunity of studying the sensations imparted to the 
finger by the sutures and fontanelles in the head of the child after 
birth. 

The Diameters of the Fetal 8hiE. — For the purpose of understanding 
the mechanism of labor we must study the measurements of the foetal 
head in relation to the cavity through which it has to pass. They arc 
taken from corresponding points opposite to each other, and are known 
as the diameters of the skull (Fig. 'JO). Those of mosl importance are : 
1st. The ocmptto-mental, from tne occipital protuberance i<» the point 
of the chin, 5.25" t<> 5.50". 2d. The oeeipito-frcmtal^ from the occiput 
to the centre of the forehead, 4.50" to -V. 3d, The sxtb-occipito-breg- 



122 



PREGNANCY. 



Fig. 66. 




1 and 2. Occipitofrontal diameter. 

3 and 4. Occipito-mental. 

5 and 6. Cervico-bregmatic 

7 and 8. Fronto-mental. 



matic, from a point midway between the occipital protuberance and the 
margin of the foramen magnum to the centre of the anterior fontanelle, 
3.25". 4th. The cervico-bregmatic, from the anterior margin of the 

foramen magnum to the centre 
of the anterior fontanelle, 3. 7 5". 
5th. Transverse, or bi-parietal, be- 
tween the parietal protuberances, 
3.75" to 4". 6th. Bi-temporal, be- 
tween the ears, 3. 50". 7th. Fronto- 
mental, from the apex of the fore- 
head to the chin, 3.25". 

Alteration of Diameters by Com- 
pression and Moulding during La- 
bor. — The length of these respective 
diameters, as given by different wri- 
ters, differs considerably, a fact to be 
explained by the measurements hav- 
ing been taken at different times — 
by some just after birth, when the 
head was altered in shape by the 
moulding it had undergone ; by others when this had either been slight 
or after the head had recovered its normal shape. The above measure- 
ments may be taken as the average of those of the normally shaped head, 
and it is to be noted that the first two are most apt to be modified during 
labor. The amount of compression and moulding to which the head may 
be subjected without proving fatal to the foetus is not certainly known, 
but it is doubtless very considerable. Some interesting examples of the 
extent to which the head may be altered in shape in difficult labors have 
been given by Barnes, 1 who has shown by tracings of the shape of the head 
taken immediately after delivery that in protracted labor the occipito- 
mental and occipitofrontal diameters may be increased more than an 
inch in length, while lateral compression may diminish the bi-parietal 
diameter to the same length as the inter-auricular. The foetal head is 
movable on the vertical column to the extent of a quarter of a circle ; 
and it seems probable that the laxity of the ligaments admits with 
impunity a greater circular movement than would be possible in the 
adult. 

Influence of Sex and Race on the Fostal Head. — On taking the aver- 
age of a large number of measurements, it is found that the heads of 
male children are larger and more firmly ossified than those of females, 
the former averaging about half an inch more in circumference. Sir 
James Simpson attributed great importance to this fact, and believed 
that it was sufficient to account for the larger proportion of stillbirths 
in male than in female children, as well as for the greater difficulty of 
labor and the increased maternal mortality that are found to attend on 
male births. His well-known paper on this subject, which has given 
rise to much controversy, is full of the most elaborate details ; and so 
great did he believe the foetal influence to be that he calculated that 
between the years 1834 and 1837 there were lost in Great Britain, as 

1 Obst. Trans., vol. vii. 



THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 123 

a consequence of the slightly larger size of the male than of the 
female head at birth, about 50,000 lives, including those of about 
46,000 or 47,000 infants, and of between 3000 and 4000 mothers who 
died in childbed. 1 It is probable that race and other conditions, such 
as civilization and intellectual culture, have considerable influence on 
the size of the foetal skull, but we are not in possession of sufficiently 
accurate data to justify any very positive opinion on these points. 

Position of the Foetus in Utero. — In the very large majority of cases 
the foetus lies in utero with head downward, and is so placed as to be 
adapted in the most convenient way to the cavity in which it is placed. 
The uterine cavity is most roomy at the fundus, and narrowest at the 
cervix, and the greatest bulk of the foetus is at the breech, so that the 
largest part of the child usually lies in the part of the uterus best 
adapted to contain it. The various parts of the child's body are further 
so placed, in regard to each other, as to take up the least possible 
amount of space. (See frontispiece.) The body is bent so that the 
spine is curved with its convexity outward, this curvature existing from 
the earliest period of development ; the chin is flexed on the sternum ; 
the forearms are flexed on the arms, and lie close together on the front 
of the chest ; the legs are flexed on the thighs, and the thighs drawn up 
on the abdomen ; the feet are drawn up toward the legs ; the umbilical 
cord is generally placed out of reach of injurious pressure, in the space 
between the arms and the thighs. Variations from this attitude, how- 
ever, are not uncommon, and are not, as a rule, of much consequence. 
Although the cranial presentations are much the most common, averag- 
ing 96 out of every 100 cases, other presentations are by no means rare, 
the next most frequent being either that of the breech, in which the long 
diameter of the child lies in the long diameter of the uterine cavity, or 
some variety of transverse presentation, in which the long diameter of 
the foetus lies obliquely across the uterus, and no longer corresponds to 
its longitudinal axis. 

Changes of Foetal Position during Pregnancy. — It was long believed 
that the head presentation was only assumed toward the end of preg- 
nancy, when it was supposed to be produced by a sudden movement on 
the part of the foetus, known as the culbute. It is now well known that, 
in the large majority of cases, the head is lowest during all the latter part 
of pregnancy, although changes in position are more common than is 
generally believed to be the case, and presentation of parts other than 
the head is much more frequent in premature labor than in delivery at 
term. In evidence of the last statement, Churchill says that in labor 
at the seventh month the head presents only *'•> times out of 100 when 
the child is living, and that as many as 53 per cent, of the presentations 
arc preternatural when the child is stillborn. The frequency with 
which the foetus changes its position before delivery has been made the 
subject of investigation by various German obstetricians, and the fact 
can he readily ascertained by examination. Yalenta'- found that ont 
of nearly 1000 cases, carefully and frequently examined by him, in 
57.6 per cent, the presentation underwent no change in the latter 
months of pregnancy, but in the remaining 42.4 per cent, a change 

1 Selected Ob*i. Work*, p. 363. 2 Mon.f. Qeburt., 1866. 



124 



PREGNANCY. 



could be readily detected. These alterations were found to be most 
frequent in multipara^ and the tendency was for abnormal presentations 
to alter into normal ones. Thus it was common for transverse pres- 
entations to alter longitudinally, and but rare for breech presentations 
to change into head. The ease with which these changes are effected no 
doubt depends, in a considerable degree, on the laxity of the uterine 
parietes and on the greater quantity of amniotic fluid, by both of which 
the free mobility of the foetus is favored. 

Detection of Foetal Position by Abdominal Palpation. — The facility 
with which the position of the foetus in utero can be ascertained by 
abdominal palpation has not been generally appreciated in obstetric 
works, and yet by a little practice it is easy to make it out. Much 
information of importance can be gained in this way, and it is quite 
possible, under favorable circumstances, to alter abnormal presentations 
before labor has begun. For the purpose of making this examination 

Fig. 67. 




Mode of Ascertaining the Position of the Foetus by Palpation. 

the patient should lie at the edge of the bed, with her shoulders slightly 
raised and the abdomen uncovered. The first observation to make is to 
see if the longitudinal axis of the uterine tumor corresponds with that 
of the mother's abdomen ; if it does, the presentation must be either a 
head or a breech. By spreading the hands over the uterus (Fig. 67) a 
greater sense of resistance can be felt, in most cases, on one side than on 
the other, corresponding to the back of the child. By striking the tips 
of the fingers suddenly inward at the fundus, the hard breech can 
generally be made out, or the head still more easily if the breech be 
downward. When the uterine walls are unusually lax, it is often 
possible to feel the limbs of the child. These observations can be 
generally corroborated by auscultation, for in head presentations the 
foetal heart can usually be heard below the umbilicus, and in breech 
cases above it. Transverse presentations can even more easily be made 



THE AX ATOMY AND PHYSIOLOGY OF THE FCETUS. 125 

out by abdominal palpation. Here the long axis of the uterine tumor 
does not correspond with the long axis of the mother's abdomen, but 
lies obliquely across it. By palpation the rounded mass of the head 
can be easily felt in one of the mother's flanks, and the breech in the 
other, while the foetal heart is heard pulsating nearer to the side at 
which the head is detected. 

Explanation of the Position of the Foetus in Utero. — The reason why 
the head presents so frequently has been made the subject of much dis- 
cussion. The oldest theory was, that the head lay over the os uteri as 
the result of gravitation ; and the influence of gravity, although con- 
tested by many obstetricians, prominent among whom were Dubois and 
Simpson, has been insisted upon as the chief cause by others, Dr. Duncan 
being one of the most strenuous advocates of this view. The objections 
urged against the gravitation theory were drawn partly from the result 
of experiments, and partly from the frequency with which abnormal 
presentations occur in premature labors, Avhen the action of gravity 
cannot be supposed to be suspended. The experiments made by Dubois 
went to show that when the foetus was suspended in water gravitation 
caused the shoulders, and not the head, to fall lowest. He therefore 
advanced the hypothesis that the position of the foetus was due to 
instinctive movements which it made to adapt itself to the most com- 
fortable position in which it could lie. It need only be remarked that 
there is not the slightest evidence of the foetus possessing any such 
power. Simpson proposed a theory which was much more plausible. 
He assumed that the foetal position was due to reflex movements pro- 
duced by physical irritations to which the cutaneous surface of the foetus 
is subjected from changes of the mother's position, uterine contractions, 
and the like. The absence of these movements in the case of the death 
of the foetus would readily explain the frequency of mal-presentations 
under such circumstances. The obvious objection to this theory, com- 
plete as it seems to be, is the absence of any proof that such constant 
extensive reflex movements really do occur in utero. Dr. Duncan has 
very conclusively disposed of the principal objections which have been 
raised against the influence of gravitation, and when an obvious ex- 
planation of so simple a kind exists it seems useless to seek farther for 
another. He has shown that Dubois's experiments did not accurately 
represent the state of the foetus in utero, and that during the greater 
part of the day, when the woman is upright or lying on her back, the 
foetu- lies obliquely to the horizon at an angle of about 30°. The child 
thus lies, in the former case, on an inclined plane formed by the anterior 
uterine wall and by the abdominal parietes; in the latter, by the pos- 
terior uterine wall and the vertebral column. Down the inclined plane 
so formed the force <>f gravity causes the foetus to slide, and it is only 
when the woman lie- on her side that the foetus is placed horizontally, 
and is not subjected in the same degree to the action of gravity (Fig. 68). 
The frequency of mal-presentations in premature labors is explained by 
Dr. Duncan partly by the fact that the death of the child (which SO 
frequently precedes such cases) niter- its centre of gravity, and partly 
by the greater mobility of the child and the greater relative amount of 
liquor amnii (Fig. 69). The influence of gravitation is probably greatly 



126 



PREGNANCY. 



assisted by the contractions of the uterus which are going on during the 
greater part of pregnancy. The influence of these was pointed out by 
Dr. Tyler Smith, who distinctly showed that the contractions of the 
uterus preceding delivery exerted a moulding or adapting influence on 




Diagram illustrating the effect of Gravity on the Foetus. (After Duncan.) 
a, b, is parallel to the axis of the pregnant uterus and pelvic brim ; c, d, e, is a perpendicular line ; 
centre of gravity of the foetus ; d, the centre of flotation. 



the 



the foetus, and prevented undue alterations of its position. Dr. Hicks 
proved 1 that these uterine contractions are of constant occurrence from 
the earliest period of pregnancy, and there can be little doubt that they 
must have an important influence on the body contained within the 



Fig 




Illustrating the greater Mobility of the Foetus and the larger relative amount of Liquor Amnii 

in' Early Pregnancy. (After Duncan.) 

a, b. Axis of pregnant uterus. b, h. A horizontal iine. 

uterus. The whole subject has been recently considered by Pinard, 2 
who shows that many factors are in action to produce and maintain the 
usual position of the foetus in utero, which may be either of an active 
or a passive character — the former being chiefly the active movements 

1 Obst. Trans., vol. xiii. p. 216. 2 Annal. de Gyn., May and -July, 1878. 



THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 127 

of the fetus and the contractions of the uterus and the abdominal 
muscles ; the latter, the form of the uterus and the foetus, the slippery 
surface of the amnion, pressure of the amniotic fluid, etc. When any 
of these factors are at fault, mal-presentation is apt to occur. 

Functions of the Foetus. — The functions of the foetus are in the main 
the same, with differences depending on the situation in which it is placed, 
as those of the separate being. It breathes, it is nourished, it forms 
secretions, and its nervous system acts. The mode in which some of 
these functions are carried on in intra-uterine life requires separate con- 
sideration. 

Nutrition. — During the early part of pregnancy, and before the forma- 
tion of the umbilical vesicle and the allantois, it is certain that nutritive 
material must be supplied to the ovum by endosmosis through its exter- 
nal envelope. The precise source, however, from which this is obtained 
is not positively known. By some it is believed to be derived from the 
granulations of the discus proligerus which surround it as it escapes 
from the Graafian follicle, and subsequently from the layer of albumin- 
ous matter which surrounds the ovum before it reaches the uterus ; while 
others think it probable that it may come from a special liquid secreted 
by the interior of the Fallopian tube as the ovum passes along it. As 
soon as the ovum has reached the uterus there is every reason to believe 
that the umbilical vesicle is the chief source of nourishment to the 
embryo, through the channel of the omphalo-mesenteric vessels, which 
convey matters absorbed from the interior of the vesicle to the intestinal 
canal of the foetus. At this time the exterior of the ovum is covered by 
the numerous fine villosities of the primitive chorion which are imbedded 
in the mucous membrane of the uterus, and it is thought that they may 
absorb materials from the maternal system, which may be either directly 
absorbed by the embryo, or which may serve the purpose of replacing 
the nutritive matter which has been removed from the umbilical vesicle 
by the omphalo-mesenteric vessels. This point it is, of course, impossi- 
ble to decide. Joulin, however, thinks that these villi probably have 
no direct influence on the nourishment of the foetus, which is at this 
time solely effected by the umbilical vesicle, but that they absorb fluid 
from the maternal system, which passes through the amnion and forms 
the liquor amnii. As soon as the allantois is developed, vascular com- 
munication between the foetus and the maternal structures is established, 
and the temporary function of the umbilical vesicle is over: that struc- 
ture, therefore, rapidly atrophies and disappears, and the nutrition of the 
foetus is now solely carried on by means of the chorion villi, lined as 
they now are by the vascular endo-chorion, and chiefly by those which 
go to form the substance of the placenta. 

This statement is opposed to the views of many physiologists, who 
believe that a certain amount of nutritive material is conveyed to the 
foetus through the channel of the liquor amnii, itself derived from the 
maternal system, which is supposed either to be absorbed through the 
cutaneous surface of the foetus or carried to the intestinal canal by deglu- 
tition. The reasons for assigning to the liquor ;i nutritive function are, 
however, so slighl that it is difficult to believe that it has anv apprecia- 
ble action in this way. They are based on some questionable observations, 



128 PREGNANCY. 

such as those of Weydlich, who kept a calf alive for fifteen days by feeding 
it solely on liquor amnii, and the experiments of Burdach, who found the 
cutaneous lymphatics engorged in a fetus removed from the amniotic 
cavity, while those of the intestine were empty. The deglutition of the 
liquor amnii for the purposes of nutrition has been assumed from its 
occasional detection in the stomach of the foetus, the presence of which 
may, however, be readily explained by spasmodic efforts at respiration 
which the foetus undoubtedly often makes before birth, especially when 
the placental circulation is in any way interfered with, and during which 
a certain quantity of fluid would necessarily be swallowed. The quantity 
of nutritive material, however, in the liquor amnii is so small — not more 
than 6 to 9 parts of albumen in 1000 — that it is impossible to conceive 
how it could have any appreciable influence in nutrition, even if its 
absorption, either by the skin or stomach, were susceptible of proof. 

That the nutrition of the foetus is effected through the placenta is 
proved by the common observation that whenever the placental circula- 
tion is arrested, as by disease of its structure, the foetus atrophies and 
dies. The precise mode, however, in which nutritive materials are 
absorbed from the maternal blood is still a matter of doubt, and must 
remain so until the mooted points as to the minute anatomy of the pla- 
centa are settled. The various theories entertained on this subject by 
the upholders of the Hunterian doctrine of placental anatomy, and by 
those who deny the existence of a sinus system, have already been referred 
to in the chapter on the Anatomy of the Placenta, to which the reader 
is referred (pp. 111-115). 

Respiration. — One of the chief functions of the placenta, besides that 
of nutrition, is the supply of oxygenated blood to the foetus. That this 
is essential to the vitality of the foetus, and that the placenta is the site 
of oxygenation, is shown by the fact that whenever the placenta is sepa- 
rated, or the access of foetal blood to it arrested by compression of the 
cord, instinctive attempts at inspiration are made, and if aerial respira- 
tion cannot be performed the foetus is expelled asphyxiated. Like the 
other functions of the foetus during intra-uterine life, that of respiration 
has been made the subject of numerous more or less ingenious hypotheses. 
Thus, many have believed that the foetus absorbed gaseous material from 
the liquor amnii, which served the purpose of oxygenating its blood, St. 
Hilaire thinking that this was effected by minute openings in its skin, 
Beclard and others through the bronchi, to which they believed the 
liquor amnii gained access. Independently of the entire want of evi- 
dence of the absorption of gaseous materials by these channels, the theory 
is disproved by the fact that the liquor amnii contains no air which is 
capable of respiration. Serres attributed a similar function to some of 
the chorion villi, which he believed penetrated the utricular glands of 
the decidua reflexa and absorbed gas from the hydroperione, or fluid 
situated between it and the decidua vera, and in this manner he thought 
the foetal blood was oxygenated until the fifth month of intra-uterine 
life, when the placenta was fully formed. 

This hypothesis, however, rests on no accurate foundation, for it is 
certain that the chorion villi do not penetrate the utricular glands in the 
manner assumed ; or, even if they did, the mode in which the oxygen 



THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 129 

thus absorbed by the chorion villi reaches the foetus, which is separated 
from them by the amnion and its contents, would still remain unexplained. 

The mode in which the oxygenation of the foetal blood is effected 
before the formation of the placenta remains, therefore, as yet unknown. 
After the development of that organ, however, it is less difficult to under- 
stand, for the foetal blood is everywhere brought into such close contact 
with the maternal, in the numerous minute ramifications of the umbili- 
cal vessels, that the interchange of gases can readily be effected. The 
activity of respiration is doubtless much less than in extra-uterine life, 
for the waste of tissue in the foetus is necessarily comparatively small, 
from the fact of its being suspended in a fluid medium of its own tem- 
perature, and from the absence of the processes of digestion and of 
respiratory movements. The quantity of carbonic acid formed would, 
therefore, be much less than after birth, and there would be a corre- 
spondingly small call for oxygenation of venous circulation. 

Circulation. — The functions of the lungs being in abeyance, it is neces- 
sary that all the foetal blood should be carried to the placenta to receive 
oxygen and nutritive materials'. To understand the mode in which this 
is effected we must bear in mind certain peculiarities in the circulatory 
system which disappear after birth. 

1. The two sides of the foetal heart are not separate, as in the adult. 
The right ventricle in the adult sends all the venous blood to the lungs 
through the pulmonary arteries, to be aerated by contact with the atmo- 
sphere. In the foetus, however, only sufficient blood is passed through 
the pulmonary arteries to ensure their being pervious and ready to carry 
blood to the lungs immediately after birth. 

An aperture of communication, the foramen ovale, exists between the 
two auricles, which is arranged so as to permit the blood reaching the 
right auricle to pass freely into the left, but not vice versa. By this 
means a large portion of the blood reaching the heart through the venae 
cavse, instead of passing, as in the adult, into the right ventricle, is 
directed into the left auricle. 

2. Even with this arrangement, however, a larger portion of blood 
would pass into the pulmonary arteries than is required for transmission to 
the lungs, and a further provision is made to prevent 
its going to them by means of a foetal vessel, the 
ductus arteriosus (Fig. 70), which arises from the 
point of bifurcation of the pulmonary arteries and 
opens into the arch of the aorta. In consequence 
of this arrangement only a very small portion of 
the blood reaches the lungs at all. 

3. The foetal hypogastric arteries are continued 
into large arterial trunks, which, passing into the 
cord, form the umbilical arteries, raid carry the im- Diagram of Foetal Heart, 
pure foetal blood into the placenta. ( JAfter Daiton.) 

4. The purified blood is collected into the single ->. pulmonary artery. 
umbilical vein, through which it is carried to the } ^^SSSSS^ 
under surface of the liver, from which point it is 

conducted, by means of another special foetal vessel, the duel us venoms, 
into the ascending vena cava and the right auricle. 




130 PREGNANCY. 

Course of the Foetal Circulation. — In order to understand the course 
of the foetal blood, it may be most conveniently traced from the point 
where it reaches the under surface of the liver through the umbilical 
vein. Part of it is distributed to the liver itself, but the greater quan- 
tity is carried directly into the inferior vena cava through the ductus 
venosus. The inferior vena cava also receives the blood from the foetal 
veins of the lower extremities and that portion of the blood of the um- 
bilical vein which has passed through the liver. This mixed blood is 
carried up to the right auricle, from which by far the greater part of it 
is immediately directed into the left auricle through the foramen ovale. 
From thence it passes into the left ventricle, which sends the greater 
part of it into the head and upper extremities through the aorta, a com- 
paratively small quantity being transmitted to the inferior extremities. 
The blood which is thus sent to the upper part of the body is collected 
into the vena cava superior, by which it is thrown into the right auricle. 
Here the mass of it is probably directed into the right ventricle, which 
expels it into the pulmonary arteries, and from thence, through the duc- 
tus arteriosus, into the descending aorta. By this arrangement it will 
be seen that the descending aorta conveys to the lower part of the body 
the comparatively impure blood which has already circulated through 
the head, neck and upper extremities. From the descending aorta a 
small quantity of blood is conveyed to the lower extremities, the greater 
part of it being carried for purification to the placenta through the um- 
bilical arteries. 

Establishment of Independent Circulation. — As soon as the child is 
born it generally cries loudly and inflates its lungs, and, in consequence, 
the pulmonary arteries are dilated, and the greater portion of the blood 
of the right ventricle is at once sent to the lungs, from whence, after 
being arterialized, it is returned to the left auricle through the pulmonary 
veins. The left auricle, therefore, receives more blood than before, the 
right less, and, the placental circulation being arrested, no more passes 
through the umbilical vein. In consequence of this, the pressure of the 
blood in the two auricles is equalized ; the mass of the blood in the right 
auricle no longer passes into the left (the valve of the foramen ovale 
being closed by the equal pressure on both sides), but directly into the 
right ventricle, and from thence into the pulmonary arteries, and the 
ductus arteriosus soon collapses and becomes impervious. The mass of 
blood in the descending aorta no longer finds its way into the hypogas- 
tric arteries, but passes into the lower extremities, and the adult circula- 
tion is established. 

Changes in Foetal Circulation after Birth. — The changes which take 
place in the temporary vascular arrangements of the foetus prior to their 
complete disappearance are of some practical interest. The ductus arte- 
riosus, as has been said, collapses, chiefly because the mass of blood is 
drawn to the lungs, and partly, perhaps, by its own inherent contract- 
ility. Its walls are found to be thickened, and its canal closes, first in 
the centre, and subsequently at its extremities, its aortic end remaining 
longer pervious on account of the greater pressure of blood from the 
left side of the heart (Fig. 71). Practical closure occurs within a few 
days after birth, although Flourens states that it is not completely oblit- 




THE ANATOMY AND PHYSIOLOGY OF THE FCETUS. 131 

eratecl until eighteen months or two years have elapsed. 1 According to 
Schroeder, its walls unite without the formation of any thrombus. The 
foramen ovale is soon closed by its valve, which contracts adhesion with 
the edges of the aperture, so as effectually to 
occlude it. Sometimes, however, a small canal FlG - 

of communication between the two auricles 
may remain pervious for many months, or 
even a year and more, without, however, any 
admixture of blood occurring. A perma- 
nently patulous condition of this aperture, 
however, sometimes exists, giving rise to the 
disease known as cyanosis. 

The umbilical arteries and veins and the 
ductus venosus soon also become impermeable, 
in consequence of concentric hypertrophy of 
their tissue and collapse of their Avails. The Diagram of Heart of infant. 
closure of the former is aided by the forma- (After Dalton ) 

,• n i»it*j_ m k t 1- Aorta. 2. Pulmonary artery. 

tion ot coagula m the interior. According 3, 3. Pulmonary branches'. 

to Robin, a longer time than is usually sup- 4 - D ^ d . arteri0BU8 becoming ° mu 

posed elapses before they become completely 

closed, the vein remaining pervious until the twentieth or thirtieth day 

after delivery, the arteries for a month or six weeks. He has also 

described 2 a remarkable contraction of the umbilical vessels within 

their sheaths at the point where they leave the abdominal walls, which 

takes place within three or four days after birth, and seems to prevent 

hemorrhage taking place when the cord is detached. 

Function of the Liver. — The liver, from its proportionately large size, 
apparently plays an important part in the foetal economy. It is not 
until about the fifth month of utero-gestation that it assumes its charac- 
teristic structure, and forms bile, previous to that time its texture being 
soft and undeveloped. According to Claude Bernard, after this period 
one of its most important offices is the formation of sugar, which is 
found in much larger amount in the foetus than after birth. Sugar is, 
however, found in the foetal structures long before the development of 
the liver, especially in the mucous and cutaneous tissues, and it seems 
probable that these, as well as the placenta itself, then fulfil the glyco- 
genic function afterward chiefly performed by the liver. The bile is 
secreted after the fifth month of pregnancy, and passes into the intestinal 
canal, and is subsequently collected in the gall-bladder. By sonic phys- 
iologists it has been supposed that the liver during intra-uterine life was 
the chief seat of depuration of the carbonic acid contained in the venous 
blood of the foetus. It is, however, more generally believed that this 
is accomplished solely in the placenta. 

The Meconium. — The bile, mixed with the mucous secretion of the 
intestinal tract, forms the meconium, which is contained in the intestines 
of the foetus, and which collects in them during the whole period of 
intra-uterine life. It is a thick, tenacious, greenish substance, which is 
voided soon after birth in considerable quantity. 

The Urine. — Urine is certainly formed during intra-uterine life, as is 

1 Acad, des Sciences, 18-54. 2 Ibid., 1860. 



132 PREGNANCY. 

proved by the fact, familiar to all accoucheurs, that the bladder is con- 
stantly emptied instantly after birth. It has generally been supposed 
that the foetus voids its urine into the cavity of the amnion, and the 
existence of traces of urea in the liquor amnii, as well as some cases of 
imperforate urethra, in which the bladder was found to be enormously 
distended, and some cases of congenital hydronephrosis associated with 
impervious ureters, have been supposed to corroborate this assumption. 
The question has been very fully studied by Joulin, who has collected 
together a large number of instances in which there was imperforate 
urethra without any undue distension of the bladder. He holds, also, 
that the amount of urea found in the liquor amnii is far too minute to 
justify the conclusion that the urine of the foetus was habitually passed 
into it, although a small quantity may, he thinks, escape into it from 
time to time ; and he therefore believes that the urine of the foetus is 
only secreted regularly and abundantly after birth, and that during intra- 
uterine life its retention is not likely to give rise to any functional dis- 
turbance. 1 

Function of the Nervous System. — There is no doubt that the nervous 
system acts to a considerable extent during intra-uterine life, and some 
authors have even supposed that the foetus was. endowed with the power 
of making instinctive or voluntary movements for the purpose of adapt- ' 
ing itself to the form of the uterine cavity. Most probably, however, 
the movements the foetus performs are purely reflex. That it responds 
to a stimulus applied to the cutaneous nerves is proved by the experi- 
ments of Tyler Smith, who laid bare the amnion in pregnant rabbits, 
and found that the foetus moved its limbs when these were irritated 
through it. Pressure on the mother's abdomen, cold applications, and 
similar stimuli will also produce energetic foetal movements. The gray 
matter of the brain in the new-born child is, however, quite rudiment- 
ary in its structure, and there is no evidence of intelligent action of the 
nervous system until some time after birth, and, a fortiori, during preg- 
nancy. 



CHAPTER III. 
PEEGNANCY. 



As soon as conception has taken place a series of remarkable changes 
commence in the uterus, which progress until the termination of preg- 
nancy, and are well worthy of careful study. They produce those mar- 
vellous modifications which eifect the transformation of the small 
undeveloped uterus of the non-pregnant state into the large and 
fully-developed uterus of pregnancy, and have no parallel in the whole 
animal economy. 

A knowledge of them is essential for the proper comprehension of the 

1 Acad, des Sciences, p. 308. 



PREGNANCY. 



133 



phenomena of labor and for the diagnosis of pregnancy which the prac- 
titioner is so frequently called upon to make. Excluding the varieties of 
abnormal pregnancy, which will be noticed in another place, we shall 
here limit ourselves to the consideration of the modifications of the 
maternal organism which result from simple and natural gestation. 

Changes in the Uterus. — The unimpregnated uterus measures 2|- inches 
in length and weighs about 1 oz., while at the full term of pregnancy it 
has so immensely grown as to weigh 24 oz. and measure 12 inches. The 
growth commences as soon as the ovum reaches the uterus, and continues 



Fig 




Relations of the Pregnant Uterus at Sixth Month to the Surrounding Parts. (After Martin) 

uninterruptedly until delivery. In the early months the uterus is con- 
tained entirely in the cavity of the pelvis, and the increase of size is 
only apparent on vaginal examination, and that with difficulty. Before 
the third month the enlargement is chiefly in the lateral direction, so 
that the whole body of the uterus assumes more of a spherical shape 
than in the non-pregnant state. If an opportunity of examining the 
gravid uterus post-mortem should occur at this time, it will he found to 
have the form of a sphere flattened somewhat posteriorly and bulging 
anteriorly. 

After the ascent of the organ into the abdomen it develops more in 
the vertical direction, so that at term it has the form of an ovoid, with 



134 



PREGNANCY. 



Fig. 73. 



its large extremity above and its narrow end at the cervix uteri, and its 
longitudinal axis corresponds to the long diameter of the mother's abdo- 
men, provided the presentation be either of the head or the breech. The 
anterior surface is now even more distinctly projecting than before— a 
fact which is explained by the proximity of the posterior surface to the 
rigid spinal column behind, while the anterior is in relation with the lax 
abdominal parietes, which yield readily to pressure, and so allow of the 
more marked prominence of the anterior uterine wall. 

Change in Situation. — Before the gravid uterus has risen out of the 
pelvis no appreciable increase in the size of the abdomen is perceptible. 
On the contrary, it is an old observation that at this early stage of preg- 
nancy the abdomen is flatter than usual, on account of the partial de- 
scent of the uterus in the pelvic cavity as a result of its increased weight. 
As the growth of the organ advances it soon becomes too large to be 
contained any longer within the pelvis, and about the middle of the third 
or the beginning of the fourth month the fundus rises above the pelvic 
brim — not suddenly, as is often erroneously thought, but slowly and 

gradually — when it may be felt as a 
smooth rounded swelling. 

Size of Uterine Tumor at Various 
Periods of Pregnancy. — It is about this 
time that the movements of the fetus 
first become appreciable to the mother, 
when " quickening " is said to have taken 
place. Toward the end of the fourth 
month the uterus reaches to about three 
fingers' breadth above the symphysis 
pubis. About the fifth month it occu- 
pies the hypogastric region, to which it 
imparts a marked projection, and the 
alteration in the figure is now distinctly 
perceptible to visual examination. About 
the sixth month it is on a level with, or 
a little above, the umbilicus. About the 
seventh month it is about two inches 
above the umbilicus, which is now pro- 
jecting and prominent, instead of de- 
pressed, as in the non-pregnant state. 
During the eighth and ninth months it 
continues to increase until the summit of the fundus is immediately 
below the ensiform cartilage (Fig. 73). A knowledge of the size of the 
uterine tumor at various periods of pregnancy, as thus indicated, is of. 
considerable practical importance, as forming the only guide by which 
we can estimate the probable period of delivery in certain cases in which 
the usual data for calculation are absent ; as, for example, when the 
patient has conceived during lactation. 

The Uterus Sinks before Delivery — For about a week or more before 
labor the uterus generally sinks somewhat into the pelvic cavity, in con- 
sequence of the relaxation of the soft parts which precedes delivery, and 
the patient now feels herself smaller and lighter than before. This 




Size of Uterus at Various Periods of 
Pregnancy. 



PREGNANCY. 135 

change is familiar to all childbearing women, to whom it is known as 
"the lightening before labor." 

The Direction of the Uterus. — AVhile the uterus remains in the pelvis 
its longitudinal axis varies in direction, much in the same way as that 
of the non-pregnant uterus, sometimes being more or less vertical, at 
others in a state of anteversion or partial retroversion. These variations 
are probably dependent on the distension or emptiness of the bladder, as 
its state must necessarily affect the position of the movable organ poised 
behind it. After the uterus has risen into the abdomen its tendency is 
to project forward against the abdominal wall, which forms its chief 
support in front. In the erect position the long axis of the uterine 
tumor corresponds with the axis of the pelvic brim, forming an angle 
of about 30° with the horizon. In the semi-recumbent position, on the 
other hand, as Duncan 1 has pointed out, its direction becomes much 
more nearly vertical. In women who have borne many children the 
abdominal parietes no longer afford an efficient support, and the uterus 
is displaced anteriorly, the fundus in extreme cases even hanging 
downward. 

Lateral Obliquity of the Uterus. — In addition to this anterior obliq- 
uity, on account of the projection of the spinal column, the uterus is 
very generally also displaced laterally, and sometimes to a very marked 
degree, so that it may be felt entirely in one flank, instead of in the 
centre of the abdomen. In a large proportion of cases this lateral devi- 
ation is to the right side, and many hypotheses have been brought for- 
ward to explain this fact, none of them being satisfactory. Thus, it has 
been supposed to depend on the greater frequency with which women 
lie on their right side during sleep, on the greater use of the right leg 
during walking, on the supposed comparative shortness of the right 
round ligament, which drags the tumor to that side, or on the frequent 
distension of the rectum on the left side, which prevents the uterus 
being displaced in that direction. Of these the last is the cause which 
seems most constantly in operation and most likely to produce the 
effect. 

Changes in the Direction of the Cervix. — The cervix must obviously 
adapt itself to the situation of the body of the uterus. We find, there- 
fore, that in the early months, when the uterus lies low in the pelvis, it 
is more readily within reach. After the ascent of the uterus it is drawn 
up, and frequently so much so as to be reached with difficulty. When 
the uterus is much anteverted, as is so often the case, the os is displaced 
backward, so that it cannot be felt at all by the examining finger. 

Relation of the Uterus to the Surrounding Parts. — Toward the end of 
pregnancy the greater part of the anterior surface of the uterus is in 
contact with the abdominal wall, its lower portion resting on the poste- 
rior surface of the symphysis pubis. The posterior surface rests on the 
spinal column, while the small intestines are pushed to either side, the 
large intestines surrounding the uterus like an arch. 

Changes in the Uterine Parietes. — The great distension of the uterus 
during pregnancy was formerly supposed to be mainly due to the 
mechanical pressure of the enlarging ovum within it. If this were so, 
1 Researches in Obstetrics, p. 10. 



136 



PREGNANCY. 



then the uterine walls would be necessarily much thinner than in the 
non-pregnant state. This is well known not to be the case, and the 
immense increase in the size of the uterine cavity is to be explained 
by the hypertrophy of its walls. At the full period of pregnancy the 
thickness of the uterine parietes is generally about the same as that of 
the non-pregnant uterus, rather more at the placental site, and less in 
the neighborhood of the cervix. Their thickness, however, varies in 
different places, and in some women they are so thin as to admit of the 
foetal limbs being very readily made out by palpation. Their density 
is, however, always much diminished, and instead of being hard and 
inelastic they become soft and yielding to pressure. This change coin- 
cides with the commencement of pregnancy, of which it forms, as recog- 
nizable in the cervix, one of the earliest diagnostic marks. At a more 
advanced period it is of value as admitting a certain amount of yielding 
of the uterine walls to movements of the foetus, thus lessening the chance 
of their being injured. 

Changes in the Cervix during Pregnancy. — Very erroneous views 
have long been taught, in most of our standard works on midwifery, as 
to the changes which occur in the cervix uteri during pregnancy. It is 
generally stated that as pregnancy advances the cervical cavity is greatly 
diminished in length, in consequence of its being gradually drawn up so 
as to form part of the general cavity of the uterus, so that in the latter 



Fig. 74. 



Fig. 75. 





Fig. 76. 



Fig. 77. 





Supposed Shortening of the Cervix at the Third, Sixth, Eighth, and Ninth Months of Pregnancy, 

as figured in Obstetric Works. 

months it no longer exists. In almost all midwifery works accurate 
diagrams are given of this progressive shortening of the cervix (Figs. 
74 to 77). The cervix is generally described as having lost one-half 
of its length at the sixth month, two-thirds at the seventh, and to be 
entirely obliterated in the eighth and ninth. The correctness of these 
views was first called in question in recent times by Stoltz in 1826, but 
Dr. Duncan, 1 in an elaborate historical paper on the subject, has shown 

1 Researches in Obstetrics. 



PREGXAXCY. 



137 



that Stoltz was anticipated by AVeitbrech in 1750, and to a less degree 
by Roederer and other writers. This opinion is now pretty generally 
admitted to be correct, and is upheld by Cazeaux, Arthur Farre, 
Duncan, and most modern obstetricians. Indeed, various post-mortem 
examinations in advanced pregnancy have shown tnat the cavity of the 
cervix remains in reality of its normal length of one inch, and it can 
often be measured during life by the examining finger on account of its 
patulous state (Fig. 78). During the fortnight immediately preceding 

Fig. 78. 




Cervix from a Woman dying in the Eighth Month of Pregnancy. (After Duncan.) 

delivery, however, a real shortening or obliteration of the cervical 
cavity takes place ; but this, as Duncan has pointed out, seems to be 
due to the incipient uterine contractions which prepare the cervix for 
labor. 

An Apparent Shortening is always Present. — There is no doubt an 
apparent shortening of the cervix always to be detected during preg- 
nancy, but this is a fallacious and deceptive feeling, due to the soilness 
of the tissue of the cervix, which is exceedingly characteristic of preg- 
nancy, and which to an experienced finger affords one of its best diag- 
nostic marks. 

Softening of the Cervix. — In the non-pregnant state the tissue of the 
cervix is hard, firm, and inelastic. When conception occurs, softening 
begins at the external os, and proceeds gradually and slowly upward 
until it involves the whole of the cervix. By the end of the fourth 
month both lips of the os are thick, softened, and velvety to the touch, 
giving a sensation likened by Cazeaux to that produced by pressing on 
a table through a thick, soft cover. By the sixth month at leasl one- 
half of the cervix is thus altered, and by the eighth the whole of it, and 



138 PREGNANCY. 

so much so that at this time those unaccustomed to vaginal examination 
experience some difficulty in distinguishing it from the vaginal walls. 
It is this softening, then, which gives rise to the apparent shortening of 
the cervix so generally described, and it is an invaluable concomitant 
of pregnancy, except in some rare cases in which there has been antece- 
dent morbid induration and hypertrophic elongation of the cervix. If, 
therefore, on examining a woman supposed to be advanced in pregnancy, 
we find the cervix to be hard and projecting into the vaginal canal, we 
may safely conclude that pregnancy does not exist. The existence of 
softening, however, it must be remembered, will not itself justify an 
opposite conclusion, as it may be produced, to a very considerable 
extent, by various pathological conditions of the uterus. 

The Os Uteri is generally Patulous. — At the same time that the tis- 
sue of the cervix is softened its cavity is widened and the external os 
becomes patulous. This change varies considerably in primiparse and 
multipara?. In the former the external os often remains closed until the 
end of pregnancy, but even in them it generally becomes more or less 
patulous after the seventh month, and admits the tip of the examining 
finger. In women who have borne children this change is much more 
marked. The lips of the external os are in them generally fissured and 
irregular, from slight lacerations of its tissue in former labors. It is also 
sufficiently open to admit the tip of the finger, so that in the latter 
months of pregnancy it is often quite possible to touch the membranes, 
and through them to feel the presenting part of the child. 

Changes in the Texture of the Uterine Tissues: The Peritoneal Coat. 
— The remarkable increase in size of the uterus during pregnancy is, as 
Ave have seen, chiefly to be explained by the growth of its structures, all 
of which are modified during gestation. The peritoneal covering is con- 
siderably increased, so as still to form a complete covering to the uterus 
when at its largest size. William Hunter supposed that its extension 
was effected rather by the unfolding of the layers of the broad ligament 
than by growth. That the layers of the broad ligament do unfold dur- 
ing gestation, especially in the early months, is probable ; but this is not 
sufficient to account for the complete investment of the uterus, and it is 
certain that the peritoneum grows pari passu with the enlargement of 
the uterus. In addition, there is a new formation of fibrous tissue 
between the peritoneal and the muscular coats, which affords strength 
and diminishes the risk of laceration during labor. 

The Muscular Coat. — The hypertrophy of the muscular tissue of the 
uterus is, however, the most remarkable of the changes produced by 
pregnancy. Not only do the previously existing rudimentary fibre-cells 
become enormously increased in size — so as to measure, according to 
Kolliker, from seven to eleven times their former length and from two 
to five times their former breadth — but new unstriped fibres are largely 
developed, especially in the inner layers. These new cells are chiefly 
found in the first months of pregnancy, and their growth seems to be 
completed by the sixth month. The connective tissue between the mus- 
cular layers is also largely increased in amount. The weight of the 
muscular tissue of the gravid uterus is therefore much increased, and it 
has been estimated by Heschl that it weighs at term from 1 to 1.5 lbs. ; 



pregnancy: 139 

that is, about sixteen times more than in the uni impregnated state. This 
great development of the muscular tissue admits of its dissection in a 
way which is quite impossible in the unimpregnated state, and the 
researches of Helie (p. 61) enable us to understand much better than 
before how the muscles forming the walls of the gravid uterus act during 
the expulsion of the child. 

The changes in the mucous coat of the uterus which result in the for- 
mation of the decidua have already been discussed at length elsewhere 
(p. 103). 

Circulatory Apparatus. — The circulatory apparatus of the uterus dur- 
ing pregnancy has been described when the anatomy of the placenta was 
under consideration (p. 111). 

Lymphatics. — The lymphatics are much increased in size, and recent 
theories on the production of certain puerperal diseases attribute to 
them a more important action than has been commonly assigned to 
them. 

Nerves. — The question of the growth of the nerves has been hotly dis- 
cussed. Robert Lee took the foremost place among those who main- 
tained that the nerves of the uterus share the general growth of its other 
constituent parts. Dr. Snow Beck, however, believed that they remain 
of the same size as in the unimpregnated state ; and this view is sup- 
ported by Hirschfeld, Robin, and other recent writers. Robin thought 
that there is an apparent increase in the size of the nerve-tubes, which, 
however, is really due to increase in the neurilemma. Kilian describes 
the nerves as increasing in length, but not in thickness ; while Schroeder 
states that they participate equally with the lymphatics in the enlarge- 
ment the latter undergo. Whichever of these views may ultimately be 
found to be correct, it is certain that analogy would lead us to expect an 
increase of nervous as well as of vascular supply. 

General Modifications in the Body produced by Pregnancy. — It is not 
in the uterus alone that pregnancy is found to produce modifications of 
importance. There are few of the more important functions of the body 
which are not, to a greater or less extent, aifected : to some of these it is 
necessary briefly to direct attention, inasmuch as, when carried to excess, 
they produce those disorders which often complicate gestation and which 
prove so distressing and even dangerous to the patients. Such of them 
as are apparent and may aid us in diagnosis are discussed in the chapter 
which treats of the signs and symptoms of pregnancy : in this place it 
is only necessary to refer to those which do not properly fall into that 
category. 

Changes in the Blood. — Amongst those which are most constant and 
important are the alterations in the composition of the blood. The 
opinion of the profession on this subject has of late years undergone a 
remarkable change. Formerly it was universally believed that preg- 
nancy was, as the rule, associated with a condition analogous to plethora, 
and that this explained many characteristic phenomena of common 
occurrence, such as headache, palpitation, singing in the v[\v>, shortness 
of breath, and the like. As a consequence, it was the habitual custom, 
not yet by any means entirely abandoned, to treat pregnant women on 
an antiphlogistic system — to place them on low diet, to administer low- 



140 PREGNANCY. 

ering remedies, and very often to practise venesection, sometimes to a 
surprising extent. Thus it was by no means rare for women to be bled 
six or eight times during the latter months, even when no definite symp- 
toms of disease existed ; and many of the older authors record cases 
where depletion was practised every fortnight as a matter of routine, and 
when the symptoms were well marked even from fifty to ninety times, 
in the course of a single pregnancy. 

Composition of the Blood in Pregnancy. — Numerous careful analyses 
have conclusively proved that the composition of the blood during preg- 
nancy is very generally — perhaps it would not be too much to say 
always — profoundly altered. Thus it is found to be more watery, its' 
serum is deficient in albumen, and the amount of colored globules is 
materially diminished, averaging, according to the analysis of Becquerel 
and Rodier, 111.8 against 127.2 in the non-gravid state. At the same 
time the amount of fibrin and of extractive matter is considerably 
increased. The latter observation is of peculiar importance, as it goes 
far to explain the frequency of certain thrombotic affections observed in 
connection with pregnancy and delivery : this hyperinosis of the blood 
is also considerably increased after labor by the quantity of effete mate- 
rial thrown into the mother's system at that time to be got rid of by her 
emunctories. The truth is, that the blood of the pregnant woman is 
generally in a state much more nearly approaching the condition of 
anaemia than of plethora, and it is certain that most of the phenomena 
attributed to plethora may be explained equally well and better on this 
view. These changes are much more strongly marked at the latter end 
of pregnancy than at its commencement ; and it is interesting to observe 
that it is then that the concomitant phenomena alluded to are most fre- 
quently met with. Cazeaux, to whom we are chiefly indebted for insist- 
ing on the practical bearing of these views, contends that the pregnant 
state is essentially analogous to chlorosis, and that it should be so treated. 
More recently the accurate observations of Willcocks l have shown that 
the blood of pregnancy differs from that of chlorosis in the fact that 
while in both the amount of haemoglobin is lessened, in pregnancy the 
individual blood-cells are not impoverished as they are in chlorosis, but 
simply lessened in comparative number, owing to an increase in the 
water of the plasma, due to the progressive enlargement of the vascular 
area during gestation. Objection has not unnaturally been taken to 
Cazeaux's theory, as implying that a healthy and normal function is 
associated with a morbid state ; and it has been suggested that this dete- 
riorated state of the blood may be a wise provision of nature instituted 
for a purpose we are not as yet able to understand. It may certainly be 
admitted that pregnancy, in a perfectly healthy state of the system, 
should not be associated with phenomena in themselves in any degree 
morbid. It must not be forgotten, however, that our patients are sel- 
dom — we might safely say never — in a state that is physiologically 
healthy. The influence of civilization, climate, occupation, diet, and a 
thousand other disturbing causes, that to a greater or less degree are 
always to be met with, must not be left out of consideration. Making 

1 " Comparative Observations on the Blood in Chlorosis and Pregnancy," by Fred. 
Willcocks, M. D., The Lancet, December 3, 1881. 



PREGNANCY. 141 

every allowance, therefore, for the undoubted fact that pregnancy ought 
to be a perfectly healthy condition, it must be conceded, I think, that in 
the vast majority of cases coming under our notice it is not entirely so ; 
and the deductions drawn by Cazeaux from the numerous analyses 
of the blood of pregnant women seem to point strongly to the conclu- 
sion that the general blood-state is tending to poverty and anaemia, and 
that a depressing and antiphlogistic treatment is distinctly contraindi- 
cated. 

Modifications in Certain Viscera. — Closely connected with the altered 
condition of the blood is the physiological hypertrophy of the heart 
which is now well known to occur during pregnancy. This was first 
pointed out by Larcher in 1828, and it has been since verified by 
numerous observers. It seems to be constant and considerable, and to 
be a purely physiological alteration, intended to meet the increased 
exigencies of the circulation which the complex vascular arrangements 
of the gravid uterus produce. The hypertrophy is limited to the left 
ventricle, the right ventricle, as well as both auricles, being unaffected. 
Blot estimates that the whole weight of the heart increases one-fifth 
during gestation. The more recent researches of Lohlein 1 render it 
probable that the hypertrophy is less than those authors have supposed. 
According to Duroziez 2 the heart remains enlarged during lactation, but 
diminishes in size immediately after delivery in women who do not 
suckle, while in women who have borne many children it remains 
permanently somewhat larger than in nullipara?. Similar increase in 
the size of other organs has been pointed out by various writers ; as, for 
example, in the lymphatics, the spleen, and the liver. Tarnier states 
that in women who have died after delivery the organs always show 
signs of fatty degeneration. According to Gassner, the whole body 
increases in weight during the latter months of pregnancy, and this 
increase is somewhat beyond that which can be explained by the size 
of the womb and its contents. 

Formation of Osteophytes. — Irregular bony deposits between the skull 
and the dura mater, in some cases so largely developed as to line the 
whole cranium, have been so frequently detected in women who have 
died during parturition that they are believed by some to be a normal 
production connected with pregnancy. Ducrest found these osteophytes 
in more than one-third of the cases in which he performed post-mortem 
examinations during the puerperal period. Rokitansky, who corrobo- 
rated the observation, believed this peculiar deposit of bony matter to 
be a physiological and not a pathological condition connected with 
pregnancy; but whether it be so, or how it is produced, has not yet 
been satisfactorily determined. 

Changes in the Nervous System. — More or less marked changes con- 
nected with the nervous system are generally observed in pregnancy, 
and sometimes to a very great extent. When carried to execs- they 
produce some of the most troublesome disorders which complicate 
gestation, such as alterations in the intellectual functions, changes in 
the disposition and character, morbid cravings, dizziness, neuralgia, 
syncope, and many others. They are purely functional in their cha- 

1 Zeilschrift fur Geburtshvlfe, ete.,.1876. 2 Qaz. dea ffdpit., 1868. 



142 PREGNANCY. 

racter, and disappear rapidly after delivery, and may be best described 
in connection with the disorders of pregnancy. 

Changes in the Respiratory Organs. — Respiration is often interfered 
with, from the mechanical results of the pressure of the enlarged uterus. 
The longitudinal dimensions of the thorax are lessened by the upward 
displacement of the diaphragm, and this necessarily leads to some 
embarrassment of the respiration, which is, however, compensated, to 
a great extent, by an increase in breadth of the base of the thoracic 
cavity. 

Changes in the Urine. — Certain changes, which are of very constant 
occurrence, in the urine of pregnant women have attracted much atten- 
tion, and have been considered by many writers to be pathognomonic. 
They consist in the presence of a peculiar deposit, formed when the 
urine has been allowed to stand for some time, which has received the 
name of kiestein. Its presence Avas known to the ancients, and it was 
particularly mentioned by Savonarola in the fifteenth century, but it 
has more especially been studied within the last thirty years by Eguisier, 
Golding Bird, and others. If the urine of a pregnant woman be allowed 
to stand in a cylindrical vessel, exposed to light and air, but protected 
from dust, in a period varying from two to seven days, a peculiar 
flocculent sediment, like line cotton wool, makes its appearance in the 
centre of the fluid, and soon afterward rises to the surface and forms a 
pellicle, which has been compared to the fat on cold mutton-broth. 
In the course of a few days the scum breaks up and falls to the bottom 
of the vessel. On microscopic examination it is found to be composed 
of fat particles, with crystals of ammoniaco-magnesium phosphates and 
phosphate of lime and a large quantity of vibriones. These appearances 
are generally to be detected after the second month of pregnancy, and 
up to the seventh or eighth month, after which they are rarely produced. 
Regnauld explains their absence during the latter months of gestation 
by the presence in the urine at that time of free lactic acid, which 
increases its acidity and prevents the decomposition of the urea into 
carbonate of ammonia. He believes that kiestein is produced by the 
action of free carbonate of ammonia on the phosphate of lime con- 
tained in the urine, and that this reaction is prevented by the excess 
of acid. 

Golding Bird believed kiestein to be analogous to casein, to the 
presence of which lie referred it, and he states that he has found it in 
twenty-seven out of thirty cases. Braxton Hicks so far corroborates 
his view, and states that the deposit of kiestein can be much more 
abundantly produced if one or two teaspoonfuls of rennet be added to 
the urine, since that substance has the property of coagulating casein. 
Much less importance, however, is now attached to the presence of 
kiestein than formerly, since a precisely similar substance is sometimes 
found in the urine of the non-pregnant, especially in anaemic women, 
and even in the urine of men. Parkes states that it is not of uniform 
composition — that it is produced by the decomposition of urea, and 
consists of the free phosphates, bladder mucus, infusoria, and vaginal 
discharges. Neugebauer and Vogel give a similar account of it, and 
hold that it is of no diagnostic value. That it is of interest, as indi- 



SIGNS AXD SYMPTOMS OF PREGNANCY. 143 

eating the changes going on in connection with pregnancy, is certain « 
but inasmuch as it is not of invariable occurrence, and may even exist 
quite independently of gestation, it is obviously quite undeserving of 
the extreme importance that has been attached to it. 

[Although not a reliable test of pregnancy, it is a remarkable fact 
that in all the cases of suspected pregnancy in private practice in which 
I have employed it I never found a woman who proved to be impreg- 
nated in whose urine it did not appear. When Dr. Kane was preparing 
his thesis on kiestein he examined a large number of specimens of urine 
and considered the test a good one ; but the fact that it may be found 
in the urine of the non-pregnant destroys its reliability for general use 
in diagnosis. — Ed.] 

Glycosuria in Pregnancy. — Toward the end of pregnancy sugar may 
sometimes be detected in the urine, and after delivery and during lacta- 
tion it exists in considerable abundance ; thus, out of thirty-five case- 
tested in the Simpson Memorial Hospital in Edinburgh during the 
puerperium, it was found in all, the amount varying from 1 to 8 per 
cent. 1 Kaltenbach has shown that this temporary glycosuria is due to 
the presence of milk-sugar in the urine, and that it ceases with the 
disappearance of milk from the breasts. 2 This physiological glycosuria 
must be carefully distinguished from true diabetes, which is a grave 
complication of pregnancy. 



CHAPTER IV. 

SIGNS AXD SYMPTOMS OF PREGNANCY. 

Importance of the Subject. — In attempting to ascertain the presence or 
absence of .pregnancy the practitioner has before him a problem which 
is often beset with great difficulties, and on the proper solution of which 
the moral character of his patient, as well as his own professional repu- 
tation, may depend. The patient and her friends can hardly be expected 
to appreciate the fact that it is often far from easy to give a positive 
opinion on the point ; and it is always advisable to use much caution 
in the examination, and not to commit ourselves to a positive opinion, 
except on the most certain grounds. This is all the more important 
because it is just in those cases in which our opinion is most fre- 
quently asked that the statements of the patient are of least value, as 
she is either anxious to conceal the existence of pregnancy, or, if desirous 
of an affirmative diagnosis, unconsciously colors \wv statements, so as t«» 
bias the judgment of the examiner. 

Classification, — Constant attempts have been made to classify the signs 

of pregnancy : thus, some divide them into the natural and sensible signs, 

others into the presumptive, the probable^ and the <-crf<iiii. The latter 

classification, which is that adopted by Montgomery in hi- classical wort 

1 Edin. Med. Joum., Aug., 1881. a Zeit. f. Oyncsk., September 13, 1-7!'. 



144 PREGNANCY. 

on the Signs and Symptoms of Pregnancy, is no doubt the better of the 
two, if any be required. The simplest way of studying the subject, 
however, is the one now generally adopted, of considering the signs of 
pregnancy in the order in which they occur, and attaching to each an 
estimate of its diagnostic value. 

Signs of a Fruitful Conception. — From the earliest ages authors have 
thought that the occurrence of conception might be ascertained by cer- 
tain obscure signs, such as a peculiar appearance of the eyes, swelling of 
the neck, or by unusual sensations connected with a fruitful intercourse. 
All of these, it need hardly be said, are far too uncertain to be of the 
slightest value. The last is a symptom on which many married women 
profess themselves able to depend, and one to which Cazeaux is inclined 
to attach some importance. 

Cessation of Menstruation. — The first appreciable indication of preg- 
nancy on which any dependence can be placed is the cessation of the 
customary menstrual discharge, and it is of great importance, as forming 
the only reliable guide for calculating the probable period of delivery. 
In women who have been previously perfectly regular, in whom there is 
no morbid cause which is likely to have produced suppression, the non- 
appearance of the catamenia may be taken as strong presumptive evi- 
dence of the existence of pregnancy ; but it can never be more than this, 
unless verified and strengthened by other signs, inasmuch as there are 
many conditions besides pregnancy which may lead to its non-appear- 
ance. Thus, exposure to cold, mental emotion, general debility, espe- 
cially when connected with incipient phthisis, may all have this effect. 
Mental impressions are peculiarly liable to mislead in this respect. It 
is far from uncommon in newly-married women to find that menstru- 
ation ceases for one or more periods, either from the general disturbance 
of the system connected with the married life or from a desire on the 
part of the patient to find herself pregnant. Also in unmarried women 
who have subjected themselves to the risk of impregnation mental 
emotion and alarm often produce the same result. 

Menstruation during Pregnancy. — A further source of uncertainty 
exists in the fact that in certain cases menstruation may go on for one 
or more periods after conception, or even during the whole pregnancy. 
The latter occurrence is certainly of extreme rarity, but one or two in- 
stances are recorded by Perfect, Churchill, and other writers of authority, 
and therefore its possibility must be admitted. The former is much less 
uncommon, and instances of it have probably come under the observation 
of most practitioners. The explanation is now well understood. During 
the early months of gestation, when the ovum is not yet sufficiently 
advanced in growth to fill the whole uterine cavity, there is a considerable 
space between the decidua reflexa which surrounds it and the decidua 
vera lining the uterine cavity. It is from this free surface of the decidua 
vera that the periodical discharge comes, and there is not only ample 
surface for it to come from, but a free channel for its escape through 
the os uteri. After the third month the decidua reflexa and the decidua 
vera blend together, and the space between them disappears. Menstru- 
ation after this time is therefore much more difficult to account for. It 
is probable that in many supposed cases occasional losses of blood from 



SIGNS AND SYMPTOMS OF PREGNANCY. 145 

other sources, such as placenta praevia, an abraded cervix uteri, or a 
small polypus, have been mistaken for true menstruation. If the dis- 
charge really occurs periodically after the third month, it can only come 
from the canal of the cervix. The occurrence, however, is so rare that 
if a woman is menstruating regularly and normally who believes herself 
to be more than four months advanced in pregnancy, W r e are justified 
ipso facto in negativing her supposition. In an unmarried woman all 
statements as to regularity of menstruation are absolutely valueless, for 
in such cases nothing is more common than for the patient to make false 
statements for the express purpose of deception. " 

Pregnancy sometimes occurs when Menstruation is normally Absent. — 
Conception may unquestionably occur when menstruation is normally 
absent. This is far from uncommon in women during lactation, when 
the function is in abeyance, and who therefore have no reliable data for 
calculating the true period of their delivery. Authentic cases are also 
recorded in which young girls have conceived before menstruation is 
established, and in which pregnancy has occurred after the change of life. 

Estimate of its Diagnostic Value. — Taking all these facts into account, 
we can only look upon the cessation of menstruation as a fairly pre- 
sumptive sign of pregnancy in women in whom there is no clear reason 
to account for it, but one which is undoubtedly of great value in 
assisting our diagnosis. 

Sympathetic Disturbances. — Shortly after conception various sympa- 
thetic disturbances of the system occur, and it is only very exceptionally 
that these are not established. They are generally most developed in 
women of highly nervous temperament ; and they are, therefore, most 
marked in patients in the upper classes of society, in whom this kind of 
organization is most common. 

Morning Sickness. — Amongst the most frequent of these are various 
disorders of the gastro-intestinal canal. Nausea or vomiting is very 
common ; and as it is generally felt on first rising from the recumbent 
position, it is popularly known amongst women as the " morning sick- 
ness." It sometimes commences almost immediately after conception, 
but more frequently not until the second month, and it rarely lasts after 
the fourth month. Generally there is nausea rather than actual vomit- 
ing. The woman feels sick and unable to eat her breakfast, and often 
brings up some glairy fluid. In other cases she actually vomits ; and 
sometimes the sickness is so excessive as to resist all treatment, seriously 
to affect the patient's health, and even imperil her life. These grave 
forms of the affection will require separate consideration. 

(huse of the S/c/:nc.ss. — Very different opinions have been held as to 
the cause of morning sickness. Dr. Henry Bennet believes thai when 
at all severe it is always associated with congestion and inflammation of 
the cervix uteri. Dr. Graily Hewitt maintains that it depends entirely 
on flexion of the uterus, producing irritation of the uterine nerves at the 
seat of the flexion, and consequent sympathetic vomiting. This theory, 
when broached at the Obstetrical Society, was received with little favor: 
it seems to me to be sufficiently disproved by the fact, which I believe 
to be certain, that more or less nausea is a normal aixl nearly constant 
phenomenon in pregnancy, for it is difficult to believe that nearly every 
10 



146 PREGNANCY. 

pregnant woman has a flexed uterus. The generally received explanation 
is probably the correct one — viz. that nausea., as well as other forms of 
sympathetic disturbance, depends on the stretching of the uterine fibres 
by the growing ovum, and consequent irritation of the uterine nerves. 
It is, therefore, one, and only one, of the numerous reflex phenomena nat- 
urally accompanying pregnancy. It is an old observation that when the 
sickness of pregnancy is entirely absent, other, and generally more dis- 
tressing, sympathetic derangements are often met with, such as a tendency 
to syncope. Dr. Bedford l has laid especial stress on this point, and main- 
tains that under such circumstances women are peculiarly apt to miscarry. 

Other derangements of the digestive functions, depending on the same 
cause, are not uncommon, such as excessive or depraved appetite, the 
patient showing a craving for strange and even disgusting articles of diet. 
These cravings may be altogether irresistible, and are popularly known 
as " longings/' Of a similar character is the disturbed condition of the 
bowels frequently observed, leading to constipation, diarrhoea, and exces- 
sive flatulence. 

Other Sympathetic Phenomena. — Certain glandular sympathies may be 
developed, one of the most common being an excessive secretion from 
the salivary glands. A tendency to syncope is not infrequent, rarely 
proceeding to actual fainting, but rather to that sort of partial syncope, 
unattended with complete loss of consciousness, which the older authors 
used to call " lypothaemia." This often occurs in women who show no 
such tendency at other times, and when developed to any extent it forms 
a very distressing accompaniment of pregnancy. Toothache is common, 
and is not rarely associated with actual caries of the teeth. When any 
of these phenomena are carried to excess, it is more than probable that 
some morbid condition of the uterus exists which increases the local 
irritation producing them. 

Mental Peculiarities. — Mental phenomena are very general. An undue 
degree of despondency, utterly beyond the patient's control, is far from 
uncommon ; or a change which renders the bright and good-tempered 
woman fractious and irritable ; or even the more fortunate but less com- 
mon change, by which a disagreeable disposition becomes altered for the 
better. 

The Diagnostic Value of these Sympathetic Disturbances is Small. — 
All these phenomena of exalted nervous susceptibility are but of slight 
diagnostic value. They may be taken as corroborating more certain 
signs, but nothing more, and they are chiefly interesting from their tend- 
ency to be carried to excess and to produce serious disorders. 

Mammary Changes. — Certain changes in the mammae are of early 
occurrence, dependent, no doubt, on the intimate sympathetic relations 
at all times existing between them and the uterine organs, but chiefly 
required for the purpose of preparing for the important function of lac- 
tation, which on the termination of pregnancy they have to perform. 

Changes in the Areolce. — Generally about the second month of preg- 
nancy the breasts become increased in size and tender. As pregnancy 
advances they become much larger and firmer, and blue veins may be 
seen coursing over them. The most characteristic changes are about the 

1 Diseases of Wpmen and Children, p. 551. 



SIGNS AND SYMPTOMS OF PREGNANCY. 



147 



nipples and areolae. The nipples become turgid, and are frequently cov- 
ered with minute branny scales, formed by the desiccation of sero-lactes- 
cent fluid oozing from them. The areolae become greatly enlarged and 
darkened from the deposit of pigment (Fig. 79). The extent and degree 
of this discoloration vary much in different women. In fair women it 
may be so slight as to be hardly appreciable, while in dark women it is 

Fig. 79. 







Appearance of the Areola in Pregnancy. 

generally exceedingly characteristic, sometimes forming a nearly black 
circle extending over a great part of the breast. The areola becomes 
moist as well as dark in appearance, and is somewhat swollen, and a 
number of small tubercles are developed upon it, forming a circle of 
projections round the nipple. These tubercles are described by Mont- 
gomery as being intimately connected with the lactiferous ducts, some 
of which may occasionally be traced into them and seem to open on their 
summits. As pregnancy advances they increase in size and number. 
During the latter months what has been called "the secondary areola " 
is produced, and when well marked presents a very characteristic appear- 
ance. It consists of a number of minute discolored spots all round the 
outer margin of the areola, where the pigmentation is fainter, and which 
are generally described as resembling spots from which the color has 
been discharged by a shower of water-drops. This change, like the 
darkening of the primary areola, is more marked in brunettes. At this 
period, especially in women whose skin is of fine texture, whitish silvery 
streaks are often seen on the breasts. They are produced by the stretch- 
ing of the cutis vera, and arc permanent. 

By pressure on the breasts a small drop of serous-looking fluid can 
very generally be forced out from the nipple, often as early as the third 
month, and on microscopic examination milk and cholostrum-globules 
can be seen in it. 



148 PREGNANCY. 

Diagnostic Value of Mammary Changes. — The diagnostic value of 
these mammary changes has been variously estimated. When well 
marked they are considered by Montgomery to be certain signs of preg- 
nancy. To this statement, however, some important limitations must be 
made. In women who have never borne children they no doubt are so ; 
for, although various uterine and ovarian diseases produce some darken- 
ing of the areola, they certainly never produce the well-marked changes 
above described. In nmltiparae, however, the areolae often remain per- 
manently darkened, and in them these signs are much less reliable. In 
first pregnancies the presence of milk in the breasts may be considered 
an almost certain sign, and it is one which I have rarely failed to detect 
even from a comparatively early period. It is true that there are authen- 
ticated instances of non-pregnant women having an abundant secretion 
of milk established from mammary irritation. Thus, Baudelocque pre- 
sented to the Academy of Surgery of Paris a young girl, eight years of 
age, who had nursed her little brother for more than a month. Dr. 
Tanner states — I do not know on what authority — that " it is not uncom- 
mon in Western Africa for young girls who have never been pregnant to 
regularly employ themselves in nursing the children of others, the mam- 
mae being excited to action by the application of the juice of one of the 
Euphorbiaceae." Lacteal secretion has even been noticed in the male breast. 
But these exceptions to the general rule are so uncommon as merely to 
deserve mention as curiosities ; and I have hardly ever been deceived in 
diagnosing a first pregnancy from the presence of even the minutest 
quantity of lacteal secretion in the breasts, although even then other 
corroborative signs should always be sought for. In multiparas the pres- 
ence of milk is by no means so valuable, for it is common for milk to 
remain in the mammae long after the cessation of lactation, even for sev- 
eral years. Tyler Smith correctly says that " suppression of the milk 
in persons who are nursing and liable to impregnation is a more valua- 
ble sign of pregnancy than the converse condition." This is an observa- 
tion I have frequently corroborated. 

As a diagnostic sign, therefore, the mammary appearances are of great 
importance in primiparae, and when well marked they are seldom likely 
to deceive. They are specially important when we suspect pregnancy in 
the unmarried, as we can easily make an excuse to look at the breast 
without explaining to the patient the reason ; and a single glance, espe- 
cially if the patient be dark-complexioned, may so far strengthen our sus- 
picion as to justify a more thorough examination. In married multiparas 
they are less to be depended upon. 

Other Pigmentary Changes. — In connection with this subject may be 
mentioned various irregular deposits of pigment which are frequently 
observed. The most common is a dark-brownish or yellowish line start- 
ing from the pubes and running up to the centre of the abdomen, some- 
times as far as the umbilicus only, at others forming an irregular ring 
round the umbilicus and reaching to the epigastrium. It is, however, 
of very uncertain occurrence, being well marked in some women, while 
in others it is entirely absent. Patches of darkened skin are often 
observed about the face, chiefly on the forehead, and this bronzing some- 
times gives a very peculiar appearance. Joulin states that it only occurs 



SIGNS AND SYMPTOMS OF PREGNANCY. 149 

on parts of the face exposed to the sun, and that it is therefore most fre- 
quently observed in women of the lower order who are freely exposed to 
atmospheric influences. These pigmentary changes are of small diag- 
nostic value, and may continue for a considerable time after delivery. 

Enlargement of the Abdomen. — The progressive enlargement of the 
abdomen and the size of the gravid uterus at various periods of preg- 
nancy, as well as the method of examination by means of abdominal 
palpation, have already been described (pp. 124 and 134). 

We will now consider the well-known phenomena, produced by the 
movements of the foetus in utero, which are so familiar to all pregnant 
women. These, no doubt, take place from the earliest period of foetal 
life at which the muscular tissue of the foetus is sufficiently developed to 
admit of contraction, but they are not felt by the mother until some- 
where about the sixteenth week of utero-gestation, the precise period at 
which they are perceived varying considerably in different cases. The 
error of the law on this subject, which supposes the child not to be 
alive, or " quick/' until the mother feels its movements, is well known, 
and has frequently been protested against by the medical profession. 

Quickening. — The so-called quickening — which certainly is felt very 
suddenly by some women — is believed to depend on the rising of the 
uterine tumor sufficiently high to permit of the impulse of the foetus 
being transmitted to the abdominal walls of the mother, through the 
sensory nerves of which, its movements become appreciable. The sensa- 
tion is generally described as being a feeble fluttering, which when first 
felt not unfrequently causes unpleasant nervous sensations. As the 
uterus enlarges the movements become more and more distinct, and gen- 
erally consist of a series of sharp blows or kicks, sometimes quite appre- 
ciable to the naked eye and causing distinct projections of the abdominal 
walls. Their force and frequency will also vary during pregnancy ac- 
cording to circumstances. At times they are very frequent and distress- 
ing ; at others the foetus seems to be comparatively quiet, and they may 
even not be felt for several clays in succession, and thus unnecessary fears 
as to the death of the foetus often arise. The state of the mother's health 
has an undoubted influence upon them. They are said to increase in 
force after a prolonged abstinence from food or in certain positions of 
the body. It is certain that causes interfering with the vitality of the 
foetus often produce very irregular and tumultuous movements. They 
can be very readily felt by the accoucheur on palpating the abdomen, 
and sometimes, in the latter months, so distinctly as to leave no doubt 
as to the existence of pregnancy. They can also generally be induced 
by placing one hand on each side of the abdomen and applying gentle 
pressure, which will induce fetal motion that can he easily appreciated. 

The Diagnostic Value of Foetal Movements. — As a diagnostic sign (lie 
existence of foetal movements has always held a high place, hut care 
should be taken in relying on it. It is certain that women are them- 
selves very often in error, and fancy they feel the movements of a foetus 
when none exists, being probably deceived by irregular contractions <>f 
the abdominal muscles or flatus within the bowels. They may even 
involuntarily produce such intra-abdominal movements as may readily 



150 PREGNANCY. 

deceive the practitioner. Of course in advanced pregnancy, when the 
foetal movements are so marked as to be seen as well as felt, a mistake 
is hardly possible, and they then constitute a certain sign. But in such 
cases there is an abundance of other indications and little room for 
doubt. In questionable cases, and at an early period of pregnancy, the 
fact that movements are not felt must not be taken as a proof of the 
non-existence of pregnancy, for they may be so feeble as not to be per- 
ceptible, or they may be absent for a considerable period. 

Intermittent Uterine Contractions. — Braxton Hicks 1 has directed atten- 
tion to the value, from a diagnostic point of view, of intermittent con- 
tractions of the uterus during pregnancy. After the uterus is sufficiently 
large to be felt by palpation, if the hand be placed over it and it be 
grasped for a time without using any friction or pressure, it will be 
observed to distinctly harden in a manner that is quite characteristic. 

This intermittent contraction occurs every five or ten minutes, some- 
times oftener, rarely at longer intervals. The fact that the uterus did 
contract in this way had been previously described, more especially by 
Tyler Smith, who ascribed it to peristaltic action. But it is certain that 
no one, before Dr. Hicks, had pointed out the fact that such contractions 
are constant and normal concomitants of pregnancy, continuing during 
the whole period of utero-gestation, and forming a ready and reliable 
means of distinguishing the uterine tumor from other abdominal enlarge- 
ments. Since reading Dr. Hicks's paper I have paid considerable 
attention to this sign, which I have never failed to detect, even in the 
retro verted gravid uterus contained entirely in the pelvic cavity, and I 
am disposed entirely to agree with him as to its great value in diagnosis. 
If the hand be kept steadily on the uterus, its alternate hardening and 
relaxation can be appreciated with the greatest ease. The advantages 
which this sign has over the foetal movements are that it is constant, 
that it is not liable to be simulated by anything else, and that it is inde- 
pendent of the life of the child, being equally appreciable when the 
uterus contains a degenerated ovum or dead foetus. The only condition 
likely to give rise to error is an enlargement of the uterus in consequence 
of contents other than the results of conception, such as retained menses 
or a polypus. The history of such cases — which are, moreover, of 
extreme rarity — would easily prevent any mistake. As a corroborative 
sign of pregnancy, therefore, I should give these intermittent contrac- 
tions a high place. [I once attended the wife of a physician in her sec- 
ond pregnancy, who had lost her first child by abortion, and was sup- 
posed to be again threatened with the same misfortune. I found her 
suffering pain with each intermittent contraction, but beyond this there 
were no symptoms to indicate an expulsive design on the part of the 
uterus. These painful intermittent contractions persisted for three 
weeks, and then gradually assumed their normal character under an opi- 
ate treatment. The lady went to the full term of gestation and bore a 
child which lived. — Ed.] 

Vaginal Signs of Pregnancy. — The vaginal signs of pregnancy are of 
considerable importance in diagnosis. They are chiefly the changes 

1 06s/. Trans., v. 13. 



SIGNS AND SYMPTOMS OF PREGNANCY. 151 

which may be detected in the cervix, and the so-called ballottement, 
which depends on the mobility of the foetus in the liquor amnii. 

Softening of the Cervix. — The alterations in the density and apparent 
length of the cervix have been already described (p. 137). When preg- 
nancy has advanced beyond the fifth month the peculiar velvety soft- 
ness of the cervix is very characteristic, and affords a strong corrobora- 
tive sign, but one which it would be unsafe to rely on by itself, inasmuch 
as very similar alterations may be produced by various causes. When, 
however, in a supposed case of pregnancy advanced beyond the period 
indicated, the cervix is found to be elongated, dense, and projecting into 
the vaginal canal, the non-existence of pregnancy may be safely inferred. 
Therefore the negative value of this sign is of more importance than the 
positive. 

Ballottement. — Ballottement, when distinctly made out, is a very val- 
uable indication of pregnancy. It consists in the displacement, by the 
examining finger, of the foetus, which floats up in the liquor amnii, and 
falls back again on the tip of the finger with a slight tap which is 
exceedingly characteristic. 

Method of Examination. — In order to practise it most easily the 
patient is placed on a couch or bed in a position midway between sit- 
ting and lying, by which the vertical diameter of the uterine cavity is 
brought into correspondence with that of the pelvis. Two fingers of 
the right hand are then passed high up into the vagina in front of the 
cervix. The uterus being now steadied from without by the left hand, 
the intra-vaginal fingers press the uterine wall suddenly upward, when, 
if pregnancy exist, the foetus is displaced, and in a moment falls back 
again, imparting a distinct impulse to the fingers. When easily appre- 
ciable it may be considered as a certain sign, for although an anteflexed 
fundus or a calculus in the bladder may give rise to somewhat similar 
sensations, the absence of other indications of pregnancy would readily 
prevent error. Ballottement is practised between the fourth and seventh 
months. Before the former time the foetus, is too small, while at a later 
period it is relatively too large, and can no longer be easily made to rise 
upward in the surrounding liquor amnii. The absence of ballottement 
must not be taken as proving the non-existence of pregnancy, for it may 
be inappreciable from a variety of causes, such as abnormal presentations 
or the implantation of the placenta upon the cervix uteri. 

Vaginal Pulsation. — There are also some other vaginal signs of preg- 
nancy of secondary consequence. Amongst these is the vaginal pulsa- 
tion pointed out by Osiander, resulting from the enlargement of the 
vagina] arteries, which may sometimes be felt beating at an early period. 
Often this pulsation is very distinct, at other times it cannot be felt at 
all, and it is altogether unreliable, as a similar pulsation may be fell in 
various uterine diseases. 

Uterine Fluctuation. — Dr. Rasch lias drawn attention to a previously 
undescribed sign which he believes to he of importance in the diagnosis 
of early pregnancy. 1 It consists in the detection of fluctuation through 
the anterior uterine wall, depending on the presence of the liquor amnii. 
In order to make this out, two fingers of the right hand must he used, 

1 Brit. Med. Journ., vol. ii., 1873. 



152 PREGNANCY. 

as in ballottement, while the uterus is steadied through the abdomen. 
Dr. Rasch states that by this means the enlarged uterus in pregnancy 
can easily be distinguished from the enlargement depending on other 
causes, and that fluctuation can always be felt as early as the second 
month. If it is associated with suppressed menstruation and darkened 
areolae, he considers it a certain sign. In order to detect it, however, 
considerable experience in making vaginal examinations is essential, and 
it can hardly be depended on for general use. 

Alteration in Color of the Vagina. — A peculiar deep violet hue of the 
vaginal mucous membrane was relied on by Jacquemier and Kiuge as 
affording a readily observed indication of pregnancy. In most cases it 
is well marked ; sometimes, indeed, the change of color is very intense, 
and it evidently depends on the congestion produced by pressure of the 
enlarged uterus. The same effect., however, is constantly seen where 
similar pressure is effected by large fibroid tumors of the uterus, and, 
therefore, for diagnostic purposes it is valueless. 

Auscultatory Signs of Pregnancy. — By far the most important signs 
are those which can be detected by abdominal auscultation, and one of 
these — the hearing of the foetal heart-sounds — forms the only sign 
which per se, and in the absence of all others, is perfectly reliable. 

Discovery of Foetal Auscultation. — The fact that the sounds of the foetal 
heart are audible during advanced pregnancy was first pointed out by 
Mayor of Geneva in 1818, and the main facts in connection with foetal 
auscultation were subsequently worked out by Kergaradec, Naegele, 
Evory Kennedy, and other observers. The pulsations first become 
audible, as a rule, in the course of the fifth month or about the middle 
of the fourth month. In exceptional circumstances and by practised 
observers they have been heard earlier. Depaul believes that he de- 
tected them as early as the eleventh week, and Routh has also detected 
them at an earlier period by vaginal stethoscopy, which, however, for 
obvious reasons, cannot be ordinarily employed. Naegele never heard 
them before the eighteenth week, more generally at the end of the twen- 
tieth, and for practical purposes the pregnancy must be advanced to the 
fifth month before we can reasonably expect to detect them. From this 
period up to term they can almost always be heard— if not at the first 
attempt, at least afterward, to a certainty, if we have the opportunity of 
making repeated examinations. Accidental circumstances, such as the 
presence of an unusual amount of flatus in the intestines, may deaden 
the sounds for a time, but not permanently. Depaul only failed to hear 
them in 8 cases out of 906 examined during the last three months of 
pregnancy ; and out of 180 cases which Dr. Anderson of Glasgow care- 
fully examined, he only failed in 12, and in each of these the child was 
stillborn. They therefore form not only a most certain indication of 
pregnancy, but of the life of the foetus also. 

Description of the Sound. — The sound has always been likened to the 
double tic-tac of a watch heard through a pillow, which it closely 
resembles. It consists of two beats, separated by a short interval, the 
first being the loudest and most distinct, the second being sometimes 
inaudible. The rapidity of the foetal pulsations forms an important 
means of distinguishing them from transmitted maternal pulsations, with 



SIGNS AND SYMPTOMS OF PREGNANCY. 153 

which they might be confounded. Their average number is stated by 
Slater, who made numerous observations on this point, to be 132, but 
sometimes they reach as high as 140, and sometimes as low as 120. It 
will thus be seen that the pulsations are always much more rapid than 
those of the mother's heart, unless, indeed, the latter be unduly acceler- 
ated by transient mental emotion or disease. To avoid mistakes, when? 
ever the foetal heart is heard its rate of pulsation should be carefully 
counted and compared with that of the mother's pulse; if the rate 
differ, we may be sure that no error has been made. The rapidity of 
the foetal pulsations remains, as a rule, the same during the whole 
period of pregnancy, while their intensity gradually increases. They 
may, however, be temporarily increased or diminished in frequency by 
disturbing causes, such as the pressure of the stethoscope, which, excit- 
ing tumultuous movements of the foetus, may induce greatly increased 
frequency of its heart-beats. So also during labor, after the escape of 
the liquor amnii, when the contractions of the uterus have a very dis- 
tinct influence on the foetus, they may be greatly modified. An acceler- 
ation or irregularity of the pulsations, made out in the course of a pro- 
longed labor, may thus be of great practical importance, by indicating 
the necessity for prompt interference. Similar alterations, associated with 
tumultuous and unusual foetal movements felt by the mother toward 
the end of pregnancy, may point to danger to the life of the foetus 
during the latter months, and may even justify the induction of prema- 
ture labor. This is especially the case in women who have previously 
given birth to a succession of dead children owing to disease of the pla- 
centa, and in them careful and frequently-repeated auscultations may 
warn us of the impending danger. 

Supposed Difference of Rapidity according to the Sex of the Fostus. — 
The rapidity of the foetal heart has been supposed by some to afford a 
means of determining the sex of the child before birth. Frankenhauser, 
who first directed attention to this point, is of opinion that the average 
rate of pulsations of the heart is considerably less in male than in female 
children, averaging 124 in the minute in the former as against 144 in 
the latter. Steinbach makes the difference somewhat less — viz. 131 for 
males and 138 for females. He predicted the sex correctly by this 
means in 45 out of 57 cases, while Frankenhauser was correct in the 
whole 50 cases which he specially examined Avith reference to the point. 
Dr. Hutton of New York 1 was also correct in 7 cases he fixed on for 
trial. Devilliers found the difference in the sexes to be the same as 
Steinbach ; he attributes it, however, to the size and weight rather than 
to the sex of the child, and believes the pulsations to be least numerous 
in large and well-developed children. As male children are usually 
larger than female, he thus explains the relatively less frequent pulsa- 
tions of their hearts. Dr. Cumming of Edinburgh also believes thai 
the weight of the child has considerable influence on the frequency of 
its cardiac pulsations, so that a large female child may have a slower 
pulse than a small male. 2 The point, however, is more curious than 
practical, and the rapidity of the pulsations certainly would not jus- 
tify any positive prediction on the subject. Circumstances influencing 

1 New York Med. Journ., July, 1872-. 2 Edin. Med. Jaunt., L875. 



154 PREGNANCY. 

the maternal circulation seem to have no influence on that of the 
foetus. 

Site at which the Sounds are Heard. — The foetal heart-sounds are gen- 
erally propagated best by the back of the child, and are therefore most 
easily audible when this is in contact with the anterior wall of the 
uterus, as is the case in the large majority of pregnancies. When the 
child is placed in the dorso-posterior position the sounds have to trav- 
erse a larger amount of the liquor amnii, and are further modified by 
the interposition of the foetal limbs. They are, therefore, less easily 
heard in such cases, but even in them they can almost always be made 
out. As the foetus most frequently lies with the occiput over the brim 
of the pelvis, and the back of the child toward the left side of the 
mother, the heart-sounds are usually most distinctly audible at a point 
midway between the umbilicus and the left anterior-superior spine of 
the ilium. In the next most common position, in which the back of the 
child lies to the right lumbar region of the mother, they are generally 
heard at a corresponding point at the right side, but in this case they 
are frequently more readily made out in the right flank, being then 
transmitted through the thorax of the child, which is in contact with 
the side of the uterus. In breech cases, on the other hand, the heart- 
sounds are generally heard most distinctly above the umbilicus, and 
either to the right or left, according to the side toward which the back 
of the child is placed. It will thus be seen that the place at which the 
foetal heart-sounds are heard varies with the position of the foetus ; and 
this, when combined with the information derived from palpation, 
affords a ready means of ascertaining the presentation of the child 
before labor. The sounds are only audible over a limited space about 
two or three inches in diameter ; therefore, if we fail to detect them in 
one place, a careful exploration of the whole uterine tumor is necessary 
before we are satisfied that they cannot be heard. 

Sources of Fallacy. — The only mistake that is likely to be made is 
taking the maternal pulsations, transmitted through the uterine tumor, 
for those of the fcetal heart. A little care will easily prevent this error, 
and the frequency of the mother's pulse should always be ascertained 
before counting the supposed foetal pulsations. If these are found to be 
120 or more, while the mother's pulse is only 70 or 80, no mistake is 
possible. If the latter is abnormally quickened, greater care may be 
necessary, but even then the rate of pulsation of each will be dissimilar. 
Braxton Hicks 1 has pointed out that in tedious labor, when the mus- 
cular powers of the mother are exhausted, the muscular subsurrus may 
produce a sound closely resembling the foetal pulsation ; but error from 
this source is obviously very improbable. 

Mode of Practising Auscultation. — In listening for the foetal heart- 
sound the patient should be placed on her back, with the shoulders 
elevated and the knees flexed. The surface of the abdomen should be 
uncovered and an ordinary stethoscope employed, the end of which 
must be pressed firmly on the tumor, so as to depress the abdominal 
walls. The most absolute stillness is necessary, as it is often far from 
easy to hear the sounds. Sometimes, after failing with the ordinary 

1 Obst. Trans.,>\ol. xv. 



SIGNS AND SYMPTOMS OF PREGNANCY. 155 

stethoscope, I have succeeded with the bin-aural, which remarkably 
intensifies them.f 1 ] When once heard they are most easily counted 
daring a space of five seconds, as, on account of their frequency, it 
is not always possible to follow them over a longer period. 

Value of this Sign of Pregnancy. — When the foetal heart-sounds are 
heard distinctly, pregnancy may be absolutely and certainly diagnosed. 
The fact that we do not hear them does not, however, preclude the pos- 
sibility of gestation, for the fcetus may be dead or the sounds tempo- 
rarily inaudible. 

Umbilical Souffle. — There are some other sounds heard in auscultation 
which are of very secondary diagnostic value. One of these is the 
so-called umbilical or funic souffle, which was first pointed out by Evory 
Kennedy. It consists of a single blowing murmur, synchronous with 
the foetal heart-sounds, and most distinctly heard in the immediate 
vicinity of the point where these are most audible. Most authors 
believe it to be produced by pressure on the cord, either when it is placed 
between a hard part of the foetus and the uterine walls or is twisted 
round the child's neck. Schroeder and Hecker detected it in 14 or 15 
per cent, of all cases, and the latter believed it to be caused by flexure 
of the first portion of the cord near the umbilicus. For practical pur- 
poses it is quite valueless, and need only be mentioned as a phenomenon 
which an experienced auscultator may occasionally detect. 

The Uterine Souffle. — The uterine souffle is a peculiar single whizzing 
murmur which is almost always audible on auscultation. It varies very 
remarkably in character and position. Sometimes it is a gentle blowing 
or even musical murmur ; at others it is loud, harsh, and scraping ; some- 
times continuous, sometimes intermittent. It may also be heard at any 
point of the uterus, but most frequently low down and to one or other 
side ; more rarely above the umbilicus or toward the fundus ; and it 
often changes its position so as to be heard at a subsequent auscultation 
at a point where it was previously inaudible. It may be heard over a 
space of an inch or two only, or in some cases over the whole uterine 
tumor ; or, again, it may sometimes be detected simultaneously over two 
entire distinct portions of the uterus. It is generally to be heard earlier 
than the foetal heart-sounds, often as soon as the uterus rises above the 
brim of the pelvis, and it can almost always be detected after the com- 
mencement of the fourth month. The sound becomes curiously modified 
by the uterine contractions during labor, becoming louder and more 
intense before the pain comes on, disappearing during its acme, and again 
being heard as it goes off. Hicks attributes to a similar cause — viz. the 
uterine contractions during pregnancy — the frequent variations in the 
sound which are characteristic of it. 2 The uterine souffle is also audible 
after the death of the foetus, and it is believed by some to be modified 
and to become more continuously harsh when that event has taken place. 

Theories as to its Cause. — Very various explanations have been given 

P This instrument was the invention of the late Dr. G. P. Cammann of New York, 
and thirty years ago was known as the Cammann stethoscope. Dr. C. was an expert 
in physical explorations of the chest, and devoted his life to the study of its dis- 
eases. — Ed.] 

2 Op. cit., p. 223. 



156 PREGNANCY. 

of the causes of this sound. For long it was supposed to be formed in 
the vessels of the placenta, and hence the name "placental souffle " by 
which it is often talked of; or, if not in the placenta, in the uterine 
vessels in its immediate neighborhood. The non-placental origin of the 
sound is sufficiently demonstrated by the fact that it may be heard for a 
considerable time after the expulsion of the placenta. Some have sup- 
posed that it is not formed in the uterus at all, but in the maternal ves- 
sels, especially the aorta and the iliac arteries, owing to the pressure to 
which they are subjected by the gravid uterus. The extreme irregular- 
ity of the sound, its occasional disappearance, and its variable site, seem 
to be conclusive against this view. The theory which refers the sound 
to the uterine vessels is that which has received most adherents, and 
which best meets the facts of the case ; but it is by no means easy, or 
even possible, to account *for the exact mode of its production in them. 
Each of the explanations which have been given is open to some objec- 
tion. It is far from unlikely that the intermittent contractions of the 
uterine fibres, which are known to occur during the whole course of 
pregnancy, may have much to do with it, by modifying, at intervals, 
the rapidity of the circulation in the vessels. Its production in this 
manner may also be favored by the chlorotic state of the blood, to which 
Cazeaux and Scanzoni are inclined to attribute an important influence, 
likening it to the ansemic murmur so frequently heard in the vessels in 
weakly women. 

Its Diagnostic Value. — From a diagnostic point of view the uterine 
souffle is of very secondary importance, because a similar sound is very 
generally audible in large fibroid tumors of the uterus, and even in some 
few ovarian tumors ; it is therefore of little or no value in assisting us 
to decide the character of the abdominal enlargement. The supposed 
dependence of the sound on the placental circulation has caused its site 
to be often identified with that of the placenta. It is, however, most 
frequently heard at the lower part of the uterus, while the placenta is 
generally attached near the fundus, so that its position cannot be taken 
as any safe guide in determining the situation of that organ. 

Sounds produced by the Movements of the Foetus. — Occasionally, in 
practising auscultation, irregular sounds of brief duration may be heard 
which are not susceptible of accurate description, and which doubtless 
depend on the sudden movement of the foetus in the liquor amnii or on 
the impact of its limbs on the uterine walls. When heard distinctly 
they are characteristic of pregnancy, and they may be sometimes heard 
when the other sounds cannot be detected. They are, however, so irregu- 
lar, and so often entirely absent, that they can hardly be looked upon in 
any other light than as occasional phenomena. 

Sounds referred to Decomposition of the Liquor Amnii and to Sepa- 
ration of the Placenta. — Two other sounds have been described as being 
sometimes audible which may be mentioned as matters of interest, but 
which are of no diagnostic value. One is a rustling sound, said by Stoltz 
to be audible in cases in which the foetus is dead, and which he refers to 
gaseous decomposition of the liquor amnii ; its existence is, however, 
extremely problematical. The other is a sound heard after the birth of 
the child, and referred by Caillant to the separation of the placental 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 157 

adhesions. He describes it as a series of rapid, short scratching sounds, 
similar to those produced by drawing the nails across the seat of a horse- 
hair sofa. Simpson 1 admitted the existence of the sound, but believed 
that it is produced by the mere physical crushing of the placenta, and 
artificially imitated it out of the body by forcing the placenta through 
an aperture the size of the os uteri. 

Relative Value of the Signs and Symptoms of Pregnancy. — It will be 
seen, then, that although there are numerous signs and symptoms accom- 
panying pregnancy, many of them are unreliable by themselves, and apt 
to mislead. Those which may be confidently depended on are the pul- 
sations of the foetal heart, which, however, fail us in cases of dead chil- 
dren ; the foetal movements when distinctly made out ; ballottement ; 
the intermittent contractions of the uterus ; and to these we may safely 
add the presence of milk in the breasts, provided Ave have to do with a 
first pregnancy. 

The remainder are of importance in leading us to suspect pregnancy, 
and in corroborating and strengthening other symptoms, but they do not, 
of themselves, justify a positive diagnosis. 



CHAPTEE V 



THE DIFFERENTIAL DIAGNOSIS OF PREGNANCY. SPURIOUS PREG- 
NANCY. THE DURATION OF PREGNANCY. SIGNS OF RECENT 
PREGNANCY. 

Importance of the Subject. — The differential diagnosis of pregnancy 
has of late years assumed much importance on account of the advance 
of abdominal surgery. The cases are so numerous in which even the 
most experienced practitioners have fallen into error, and in which the 
abdomen has been laid open in ignorance of the fact that pregnancy 
existed, that the subject becomes one of the greatest consequence. For- 
tunately, it is less so from an obstetrical than from a gynaecological point 
of view, inasmuch as the converse error, of mistaking some other condi- 
tion for pregnancy, is of far less consequence, as it is one which time 
will always rectify. But even in this way carelessness may lead to very 
serious injury to the character, if not to the health, of the patient ; and 
it will be well to refer briefly to some of the conditions most liable to be 
mistaken for pregnancy, and to the mode of distinguishing them. 

Adipose enlargement of the abdomen may obscure the diagnosis by 
preventing the detection of the uterus ; and if, as is not uncommon with 
women of great obesity, it is associated with irregular menstruation, the 
increased size of the abdomen might be supposed to depend <»n preg- 
nancy. The absence of corroborative Bigns, such as auscultatory phe- 
nomena, mammary changes, and the hardness of the cervix as lilt per 
vaginam, make- it easy to avoid this error. 

1 Select, <l ObsUt. Works, i». LSI. 



158 PREGNANCY. 

Distension of the Uterus by Retained Menses, Hydrometra, etc. — Dis- 
tension of the uterus by retained menstrual fluid or watery secretion is 
an occurrence of rarity that could seldom give rise to error. Still, it 
occasionally happens that the uterus becomes enlarged in this way, some- 
times reaching even to the level of the umbilicus, and that the physical 
character of the tumor is not unlike that of the gravid uterus. The best 
safeguard against mistakes will be the previous history of the case, which 
will always be different from that of ordinary pregnancy. Retention of 
the menses almost always occurs from some physical obstruction to the 
exit of the fluid, such as imperforate hymen ; or if it occur in women 
who have already menstruated, we may usually trace a history of some 
cause, such as inflammation following an antecedent labor, which has 
produced occlusion of some part of the genital tract, The existence of 
a pelvic tumor in a girl who has never menstruated will of itself give 
rise to suspicion, as pregnancy under such circumstances is of extreme 
rarity. It will also be found that general symptoms have existed for a 
period of time considerably longer than the supposed duration of preg- 
nancy, as judged of by the size of the tumor. The most characteristic 
of them are periodic attacks of pain due to the addition, at each monthly 
period, to the quantity of retained menstrual fluid. Whenever, from any 
of these reasons, suspicion of the true character of the case has arisen, a 
careful vaginal examination will generally clear it up. • In most cases 
the obstruction will be in the vagina, and is at once detected, the vaginal 
canal above it, as felt per rectum, being greatly distended by fluid ; and 
we may also find the bulging and imperforate hymen protruding through 
the vulva. The absence of mammary changes and of ballottement will 
materially aid us in forming a diagnosis. 

Congestive Hypertrophy of the Uterus. — The engorged and enlarged 
uterus, frequently met w T ith in women suffering from uterine disease, 
might readily be mistaken for an early pregnancy if it happened to be 
associated with amenorrhcea. A little time would, of course, soon clear 
up the point, by showing that progressive increase in size, as in preg- 
nancy, does not take place. This mistake could only be made at an 
early stage of pregnancy, when a positive diagnosis is never possible. 
The accompanying symptoms — pain, inability to walk, and tenderness 
of the uterus on pressure — would prevent such an error. 

Ascitic Distension of the Abdomen. — Ascites, per se, could hardly be 
mistaken for pregnancy, for the uniform distension and evident fluctua- 
tion, the absence of any definite tumor, the site of resonance on per- 
cussion changing in accordance with alteration of the position of the 
woman, and the unchanged cervix and uterus, should be sufficient to 
clear up any doubt. Pregnancy may, however, exist with ascites, and 
this combination may be difficult to detect, and might readily be mis- 
taken for ovarian disease associated with ascites. The existence of mam- 
mary changes, the presence of the softened cervix, ballottement, and 
auscultation — provided the sounds were not masked by the surrounding 
fluid — would afford the best means of diagnosing such a case. 

Uterine and Ovarian Tumors. — One of the most frequent sources of 
difficulty is the differential diagnosis of large abdominal tumors, either 
fibroid or ovarian, or of some enlargements due to malignant disease of 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 159 

the peritoneum or abdominal viscera. The most experienced have been 
occasionally deceived under such circumstances. As a rule, the presence 
of menstruation will prevent error, as this generally continues in ovarian 
disease, while in fibroids it is often excessive. The character of the 
tumor — the fluctuation in ovarian disease, the hard nodular masses in 
fibroid — and the history of the case, especially the length of time the 
tumor has existed, will aid in diagnosis, while the absence of cervical 
softening and of auscultatory phenomena will further be of material 
value in forming a conclusion. Some of the most difficult cases to diag- 
nose are those in which pregnancy complicates ovarian or fibroid disease. 
Then the tumor may more or less completely obscure the physical signs 
of pregnancy. The usual shape of the abdomen will generally be 
altered considerably, and we may be able to distinguish the gravid 
uterus, separated from the ovarian tumor by a distinct sulcus, or with 
the fibroid masses cropping out from its surface. Our chief reliance 
must then be placed in the alteration of the cervix and in the auscul- 
tatory signs of pregnancy. 

Spurious Pregnancy. 1 — The condition most likely to give rise to errors 
is that very interesting and peculiar state known as spurious pregnancy. 
In this most of the usual phenomena of pregnancy are so strangely 
simulated that accurate diagnosis is often far from easy. There are 
hardly any of the more apparent symptoms of pregnancy which may 
not be present in marked cases of this kind. The abdomen may become 
prominent, the areolae altered, menstruation arrested, and apparent foetal 
motions felt ; and, unless suspicion is aroused and a careful physical 
examination made, both the patient and the practitioner may easily be 
deceived. 

Cases in ivhich Spurious Pregnancy occurs. — There is no period of the 
childbearing life in which spurious pregnancy may not be met with ; but 
it is most likely to occur in elderly women about the climacteric period, 
when it is generally associated with ovarian irritation connected with the 
change of life ; or in younger women, who are either very desirous of 
finding themselves pregnant, or who, being unmarried, have subjected 
themselves to the chance of being so. In all cases the mental faculties 
have much to do with its production, and there is generally either 
very marked hysteria or even a condition closely allied to insanity. 
Spurious pregnancy is by no means confined to the human race. It is 
well known to occur in many of the lower animals. Harvey related 
instances in bitches, either after unsuccessful intercourse or in connection 
with their being in heat, even when no intercourse had occurred. In 
sucli cases the abdomen swelled and milk appeared, in the mammae. 
Similar phenomena are also occasionally met with in the cow. In these 
instances, as in the human female, there is probably some morbid irrita- 
tion of the ovarian system. 

Its Signs and Symptoms. — The physical phenomena are often very 
well marked. The apparent enlargement is sometimes very great, and 
it seems to be produced by a projection forward of the abdominal con- 
tents due to depression of the diaphragm, together with rigidity of the 
abdominal muscles, and may even closely simulate the uterine tumor on 
palpation. After the climacteric it is frequently associated, as Gooch 



160 PREGNANCY. 

pointed out, with an undue deposit of fat in the abdominal walls and 
omentum, so that there may be even some dulness on percussion, instead 
of resonance of the intestines. The foetal movements are curiously and 
exactly simulated, either by involuntary contractions of the abdominal 
walls or by the movement of flatus in the intestines. The patient also 
generally fancies that she suffers from the usual sympathetic disorders 
of pregnancy, and thus her account of her symptoms will still further 
tend to mislead. 

Sometimes followed by Spurious Labor. — Not only may the supposed 
pregnancy continue, but at what would be the natural term of delivery 
all the phenomena of labor may supervene. Many authentic cases are 
on record in which regular pains came on, and continued to increase in 
force and frequency until the actual condition was diagnosed. Such 
mistakes, however, are only likely to happen when the statements of 
the patient have been received without further inquiry. When once an 
accurate examination has been made error is no longer possible. 

Methods of Diagnosis.— We shall generally .find that some of the phe- 
nomena of pregnancy are absent. Possibly menstruation, more or less 
irregular, may have continued. Examination per vaginam will at once 
clear up the case, by showing that the uterus is not enlarged and that the 
cervix is unaltered. It may then be very difficult to convince the patient 
or her friends that her symptoms have misled her, and for this purpose 
the inhalation of chloroform is of great value. As consciousness is 
abolished, the semi-voluntary projection of the abdominal muscles is pre- 
vented, the large apparent tumor vanishes, and the bystanders can be 
readily convinced that none exists. As the patient recovers the tumor 
again appears. 

Duration of Pregnancy. — The duration of pregnancy in the human 
female has always formed a fruitful theme for discussion amongst 
obstetricians. The reasons which render the point difficult of decision 
are obvious. As the large majority of cases occur in married women, 
in whom intercourse occurs frequently, there is no means of know- 
ing the precise period at which conception took place. The only 
datum which exists for the calculation of the probable date of 
delivery is the cessation of menstruation. It is quite possible, how- 
ever, and indeed probable, that conception occurred, in a considerable 
number of instances, not immediately after the last period, but immedi- 
ately before the proper epoch for the occurrence of the next. Hence, 
as the interval between the end of one menstruation and the 
commencement of the next averages 25 days, an error to that extent is 
always possible. Another source of fallacy is the fact, which has gen- 
erally been overlooked, that even a single coitus does not fix the date of 
conception, but only that of insemination. It is well known that in 
many of the lower animals the fertilization of the ovule does not take 
place until several days after copulation, the spermatozoa remaining in 
the interval in a state of active vitality within the genital tract. It has 
been shown by Marion Sims that living spermatozoa exist in the cervical 
canal in the human female some days after intercourse. It is very prob- 
able, therefore, that in the human female, as in the lower animals, a con- 
siderable but unknown interval occurs between insemination and actual 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 161 

impregnation, which may render calculations as to the precise duration 
of pregnancy altogether unreliable. 

Average Time between Cessation of Menstruation and Delivery. — A 
large mass of statistical observations exists respecting the average duration 
of gestation which has been drawn up and collated from numerous 
sources. It would serve no practical purpose to reprint the voluminous 
tables on this subject that are contained in obstetrical Avorks. They are 
based on two principal methods of calculation. First, we have the 
length of time between the cessation of menstruation and delivery. This 
is found to vary very considerably, but the largest percentage of deliveries 
occurs between the 274th and 280th day after the cessation of menstru- 
ation, the average day being the 278th ; but in individual instances very 
considerable variations both above and below these limits are found to 
exist. Next we have a series of cases, from various sources, in which 
only one coitus was believed to have taken place. These are naturally 
always open to some doubt, but, on the whole, they may be taken as 
affording tolerably fair grounds for calculation. Here, as in the other 
mode of calculation, there are marked variations, the average length of 
time, as estimated from a considerable collection of cases, being 275 days 
after the single intercourse. It may therefore be taken as certain that 
there is no definite time which we can calculate on as being the proper 
duration of pregnancy, and consequently no method of estimating the 
probable date of delivery on which we can absolutely rely. 

Methods of Predicting the Probable Date. — The prediction of the time 
at which the confinement may be expected is, however, a point of con- 
siderable practical importance, and one on which the medical attendant 
is always consulted. Various methods of making the calculation have 
been recommended. It has been customary in this country, according 
to the recommendation of Montgomery, to fix upon ten lunar months, or 
280 days, as the probable period of gestation, and, as conception is sup- 
posed to occur shortly after the cessation of menstruation, to add this 
number of days to any day within the first week after the last menstrual 
period as the most probable period of delivery. As, however, 278 days 
are found to be the average duration of gestation after the cessation of 
menstruation, and as this method makes the calculation vary from 281 
to 287 days, it is evidently liable to fix too late a date. Naegele's method 
was to count seven days from the first appearance of the last menstrual 
period, and then reckon backward three months as the probable date. 
Thus, if a patient last commenced to menstruate on August 10, counting 
in this way from August 17 would give May 17 as the probable date <>f 
delivery. 

Matthews Duncan has paid more attention than any one else to the 
prediction of the date of delivery. His method of calculating is based 
on the fact of 278 days being the average time between the cessation of 
menstruation and parturition ; and he claims to have had a greater aver- 
age of success in his predictions than on any other plan. His rule is as 
follows: " Find the (lav on which the female ceased to menstruate, or 
the first day of being what she calls 'well.' Take 1 that day nine months 
forward as 275, unless February is included, in which case it is taken as 
273 days. To this add three days in the former case, or five if February 
n 



162 



PREGNANCY. 



is in the count, to make up the 278. This 278th day should then be 
fixed on as the middle of the week, or, to make the prediction the 
more accurate, of the fortnight, in which the confinement is likely to 
occur, by which means allowance is made for the average variation of 
either excess or deficiency. 7 ' 

Various periodoscopes and tables for facilitating the calculation have 
been made. The periodoscope of Dr. Tyler Smith (sold by Messrs. John 
Smith & Co., 52 Long Acre) is very useful for reference in the consult- 
ing-room, giving at a glance a variety of information, such as the prob- 
able period of quickening, the dates for the induction of premature labor, 
etc. The following table, prepared by Dr. Protheroe Smith, is also 
easily read, and is very serviceable : 

Table fob, Calculating the Period of Utero-Gestation. 1 





Nine 


Calendar Months. 




Ten Lunar Months. 


From 


To 


Days. 
273 


To 


Days. 


January- 


1 


September 30 


October 


•7 


280 


February 


1 


October 31 


273 


November 


7 


280 


March 


1 


November 30 


275 


December 


5 


280 


April 


1 


December 31 


275 


January 


5 


280 


May 


1 


January 31 


276 


February 


4 


280 


June 


1 


February 28 


273 


March 


7 


280 


July 


1 


March 31 


274 


April 


6 


280 


August 


1 


April 30 


273 


May 


7 


280 


September 


1 


May 31 


273 


June 


7 


280 


October 


1 


June 30 


273 


July 


7 


280 


November 


1 


Julv 31 


273 


August 


7 


. 280 


December 


1 


August 31 


274 


September 


6 


280 



Quickening a Fallacious Guide in estimating Date of Delivery. — The 
date at which the quickening has been perceived is relied on by many 
practitioners, and still more by patients, in calculating the probable date 
of delivery, as it is generally supposed to occur at the middle of preg- 
nancy. The great variations, however, at the time at which this phe- 
nomenon is first perceived, and the difficulty which is so often experienced 
of ascertaining its presence with any certainty, render it a very fallacious 
guide. The only times at which the perception of quickening is likely 
to prove of any real value are when impregnation has occurred during 
lactation (when menstruation is normally absent), or when menstruation 
is so uncertain and irregular that the date of its last appearance cannot 
be ascertained. As quickening is most commonly felt during the fourth 
month — more frequently in its first than in its last fortnight — it may 
thus afford the only guide we can obtain, and that an uncertain one, for 
predicting the date of delivery. 

Is Protraction of Gestation Possible? — From a medico-legal point of 

1 The above obstetric "Ready Reckoner" consists of two columns, one of calendar, 
the other of lunar, months, and may be read as follows : A patient has ceased to men- 
struate on July 1 : her confinement may be expected at soonest about March 31 (the 
end of nine calendar months), or at latest on April 6 (the end of ten lunar months). 
Another has ceased to menstruate on January 20 : her confinement may be expected 
on September 30, plus 20 days (the end of nine calendar months), at soonest, or on 
October 7, plus 20 days (the end of ten lunar months), at latest. 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 163 

view the question of the possible protraction of pregnancy beyond the 
average time, and of the limits within which such protraction can be 
admitted, is of very great importance. The law on this point varies 
considerably in different countries. Thus, in France it is laid down that 
legitimacy cannot be contested until 300 days have elapsed from the 
death of the husband or the latest possible opportunity for sexual inter- 
course. This limit is also adopted by Austria, while in Prussia it is 
fixed at 302 days. In England and America no fixed date is admitted, 
but while 280 days is admitted as the "legitimum tempus pariendi," 
each case in which legitimacy is questioned is to be decided on its own 
merits. At the early part of the century the question was much discussed 
by the leading obstetricians in connection with the celebrated Gardner 
peerage case, and a considerable difference of opinion existed among them. 
Since that time many apparently perfectly reliable cases have been re- 
corded in which the duration of gestation was obviously much beyond 
the average, and in which all sources of fallacy were carefully excluded. 

Reliable Cases of Protraction. — Not to burden these pages with a 
number of cases, it may suffice to refer, as examples of protraction, to 
four well-known instances recorded by Simpson, 1 in which the preg- 
nancy extended respectively to 336, 332, 319, and 324 days after the 
cessation of the last menstrual period. In these, as in all cases of pro- 
tracted gestation, there is the possible source of error that impregnation 
may have occurred just before the expected advent of the next period. 
Making an allowance of 23 days in each instance for this, we even then 
have a number of days much above the average — viz. 313, 309, 296, 
and 301. Numerous instances as curious may be found scattered through 
obstetric literature. Indeed, the experience of most accoucheurs will 
parallel such cases, which may be more common than is generally sup- 
posed, inasmuch as they are only likely to attract attention when the 
husband has been separated from the wife beyond the average and 
expected duration of the pregnancy. 

Protraction Common in the Power Animals. — The evidence in favor 
of the possible prolongation of gestation is greatly strengthened by what 
is known to occur in the lower animals. In some of these, as in the 
cow and the mare, the precise period of insemination is known to a 
certainty, as only a single coitus is permitted. Many tables of this 
kind have been constructed, and it lias been shown that there is in them 
a very considerable! variation. In some cases in the cow it lias been 
found that delivery took place 45 days, and in the mare 43 days, after 
the calculated date. Analogy would go strongly to show that what is 
known to a certainty to occur in the lower animals may also take place 
in the human female. The fact, indeed, is now very generally admitted : 
but we are still unable to fix with any degree of precision on the extreme 
limit to which protraction is possible. Some practitioners have given 
cases in which, on data which they believe to be satisfactory, pregnancy 
has been extremely protracted ; thus, Meigs and Adler record instances 
which they believed to have been prolonged to over a year in one case 
and over fourteen months in the other. These are, however, so prob- 
lematical that little weight can be attached to them. On the whole, i1 

1 Obstet. Memoirs, p. 84. 



164 PREGNANCY. 

would hardly be safe to conclude that pregnancy can go more than three 
or four weeks beyond the average time. This conclusion is justified by 
the cases we possess in which pregnancy followed a single coitus, the 
longest of which was 295 days. 

Evidence from Size of Child. — Dr. Duncan 1 is inclined to refuse 
credence to every case of supposed protraction unless the size and 
weight of the child are above the average, believing that lengthened 
gestation must of necessity cause increased growth of the child. This 
point requires further investigation, and it cannot be taken as proved 
that the foetus necessarily must be large because it has been retained 
longer than usual in utero ; or, even if this be admitted, it may have 
been originally small, and so at the end of the protracted gestation be 
little above the average weight. There are, however, many cases which 
certainly prove that a prolonged pregnancy is at least often associated 
with an unusually-developed foetus. Dr. Duncan himself cites several, 
and a very interesting one is mentioned by Leishman in which delivery 
took place 295 days after a single coitus, the child weighing 12 lbs. 3 oz. 

In some cases Labor may Commence and be Arrested. — It seems 
possible that, in some cases of protracted pregnancy, labor actually 
came on at the average time, but, on account of faulty positions of the 
uterus or other obstructing cause, the pains were ineffective and ulti- 
mately died away, not recurring for a considerable time. Joulin relates 
some instances of this kind. In one of them the labor was expected 
from the 20th to the 25th of October. He was summoned on the 23d, 
and found the pains regular and active, but ineffective ; after lasting the 
whole of the 24th and 25th they died away, and delivery did not take 
place until November 25th, after the lapse of a month. In this instance 
the apparent cause of difficulty was extreme anterior obliquity of the 
uterus. A precisely similar case came under my own observation. The 
lady ceased to menstruate on March 16, 1870. On December 12th — 
that is, on the 273d day — strong labor-pains came on, the os dilated to 
the size of a florin, and the membranes became tense and prominent 
with each pain. After lasting all night they gradually died away, and 
did not recur until January 12th, 304 days from the cessation of the 
last period. Here there was no assignable cause of obstruction, and the 
labor, when it did come on, was natural and easy. 

The curious fact that in both these cases, as in others of the same 
kind that are recorded, labor came on exactly a month after the previous 
ineffectual attempt at its establishment, affords, so far as it goes, an 
argument in favor of the view maintained by many that labor is apt to 
come on at what would have been a menstrual period. 

Signs of Recent Delivery. — From a forensic point of view it often 
becomes of importance to be able to give a reliable opinion as to the 
fact of delivery having occurred, and a few words may be here said as 
to the signs of recent delivery. Our opinion is only likely to be sought 
in cases in which the fact of delivery is denied, and in which we must, 
therefore, entirely rely on the results of a physical examination. If this 
be undertaken within the first fortnight after labor, a positive conclusion 
can be readily arrived at. 

1 Fecundity and Fertility, p. 348. 



DIFFERENTIAL DIAGNOSIS OF PREGNANCY. 165 

At this time the abdominal walls will still be found loose and flaccid, 
and bearing very evident marks of extreme distension in the cracks and 
fissures of the cutis vera. These remain permanent for the rest of the 
patient's life, and may be safely assumed to be signs of an antecedent 
pregnancy, provided we can be certain that no other cause of extreme 
abdominal distension has existed, such as ascites or ovarian tumor. 

Within the first few days after delivery the hard round ball formed 
by the contracted and empty uterus can easily be felt by abdominal 
palpation, and more certainly by combined external and internal exami- 
nation. The process of involution, however, by which the uterus is 
reduced to its normal size, is so rapid that after the first week it can no 
longer be made out above the brim of the pelvis. In cases in which an 
accurate diagnosis is of importance the increased length of the uterus 
can be ascertained by the uterine sound, and its cavity will measure 
more than the normal 2^- inches for at least a month after delivery. 
It should not be forgotten that the uterine parietes are now undergoing 
fatty degeneration, and that they are more than usually soft and friable, 
so that the sound should be used with great caution and only when a 
positive opinion is essential. The state of the cervix and of the vagina 
may afford useful information. Immediately after delivery the cervix 
hangs loose and patulous in the vagina, but it rapidly contracts, and 
the internal os is generally entirely closed after the eighth or tenth day. 
The remainder of the cervix is longer in returning to its normal shape 
and consistency. It is generally permanently altered after delivery, the 
external os remaining fissured and transverse, instead of circular with 
smooth margins, as in virgins. The vagina is at first lax, swollen, and 
dilated, but these signs rapidly disappear, and cannot be satisfactorily 
made out after the first few days. The absence of the fourchette may 
be recognized, anil is a persistent sign. 

The presence of the lochia affords a valuable sign of recent delivery. 
For the first' few days they are sanguineous, and contain numerous 
blood-corpuscles, epithelial scales, and the debris of the decidua. After 
the fifth day they generally change in color and become pale and 
greenish, and from the eighth or ninth day till about a month after 
delivery they have the appearance of thick opalescent mucus. They 
have, however, a peculiar, heavy, sickening odor, which should prevent 
their being mistaken for either menstruation or leucorrhoeal discharge. 

The appearance of the breasts will also aid the decision, for it is 
impossible for the patient to conceal the turgid, swollen condition of the 
mammae, with the darkened areolae, and, above all, the presence of milk. 
If, on microscopic examination, the milk is found to contain colostrum- 
corpuscles, the fad of very recent delivery is certain. In women who 
do not nurse it should be remembered that the secretion of milk often 
rapidly disappears, SO that its absence cannot he taken as a sign that 
delivery lias not taken place. On the whole, there should he no 
difficulty in deciding that a woman has been delivered, as some of the 
signs are persistent for the rest of her life ; but it is not so easy, unless 
we see the case within the first eight or ten days, to say how long it is 
since labor took place. 



166 



PREGNANCY. 



CHAPTER VI. 

ABNORMAL PREGNANCY, INCLUDING MULTIPLE PREGNANCY, 
SUPERFCETATION, EXTRA-UTERINE FCETATION, AND MISSED 
LABOR. 



Plural Births an Abnormal Variety of Pregnancy. — The occurrence 
of more than one foetus in utero is far from uncommon, but there are 
circumstances connected with it which justify the conclusion that plural 
births must not be classified as natural forms of pregnancy. The rea- 
sons for this A statement have been well collected by Dr. Arthur Mitchell/ 
who conclusively shows that not only is there a direct increase of risk 
both to the mother and her offspring, but that many abnormalities, such 
as idiocy, imbecility, and bodily deformity, occur with much greater 
frequency in twins than in single-born children. He concludes that 
"the whole history of twin births is exceptional, indicates imperfect 
development and feeble organization in the product, and leads us to 
regard twinning in the human species as a departure from the physio- 
logical rule, and therefore injurious to all concerned." 

Frequency of Multiple Births. — The frequency of multiple births 
varies considerably under different circumstances. Taking the average 
of a large number of cases collected by authors in various countries, we 
find that twin pregnancies occur about once in 87 labors ; triplets, once 
in 7679. A certain number of quadruple pregnancies, and some cases 
of early abortion in which there were five foetuses, are recorded, so that 
there can be no doubt of the possibility of such occurrences ; but they 
are so extremely uncommon that they may be looked upon as rare 
exceptions, the relative frequency of which can hardly be determined. 

The frequency of multiple pregnancy varies remarkably in different 
races and countries. The following table 2 will show this at a glance: 

Relative Frequency of Multiple Pregnancies in Europe. 



Countries. 



England 

Austria 

Grand Duchy of Baden 

Scotland . .* 

France 

Ireland 

Mecklenburg-Schwerin 

Norway 

Prussia 

Russia 

Saxony 

Switzerland 

Wiirtemberg 

1 Med. Times and Gaz., Nov., 1862. 



Proportion of 


Twin to Single 


Births. 


1 


: 116 


1 


:94 


1 


:89 


1 


95 


1 


99 


1 


64 


1 


•68.9 


1 


: 81.62 


1 


89 


1 


50.05 


1 


79 


1 


102 


1 


862 



Proportion of 
Triplets. 



1 : 6,720 

1 : 6,575 

1 : 8,256 
1 : 4,995 
1 : 6,436 
1 : 5,442 
1 : 7,820 
1 : 4,054 
1 : 1,000 

1 : 6,464 



Proportion of 
Quadruplets. 



1 : 2,074.306 
1 : 167,226 
1 : 183,236 

1: 394,690 

1: 400,000 

1 : 110,991 



Puech, Des Naissances Multiples. 



ABNORMAL PREGNANCY. 167 

It will be seen that the largest proportion of multiple births occurs in 
Russia, and that the number of triple births is greatest where twin preg- 
nancies are most frequent. Puech concludes that the number of multi- 
ple pregnancies is in direct proportion to the general fecundity of the 
inhabitants. 

Dr. Duncan has deduced some interesting laws with regard to the 
production of twins from a large number of statistical observations ; ! 
especially, that the tendency to the production of twins increases as the 
age of the woman advances, and is greater in each succeeding pregnancy, 
exception being made for the first pregnancy, in which it is greater than 
in any other. Newly-married women appear more likely to have twins 
the older they are. There can be no doubt that there is often a strong 
hereditary tendency in individual families to multiple births. A 
remarkable instance of this kind is recorded by Mr. Curgenven, 2 in 
which a woman had four twin pregnancies, her mother and aunt each 
one, and her grandmother two. Simpson mentions a case of quad- 
ruplets, consisting of three males and one female, who all survived, the 
female subsequently giving birth to triplets. 3 

Sex of Children. — In the largest number of cases of twins the children 
are of opposite sexes, next most frequently there are two females, and 
twin males are the most uncommon. Thus, out of 59,178 labors, 
Simpson calculates that twin male and female occurred once in 199 
labors, twin females once in 226, and twin males once in 258. The 
proportion of male to female births is also notably less in twin than in 
single pregnancies. 

Size of Foetuses. — Twins, and, a fortiori, triplets, are almost always 
smaller and less perfectly developed than single children. Hence the 
chances of their survival are much less, and Clarke calculates the mor- 
tality amongst twin children as one out of thirteen. Of triplets, indeed, 
it is comparatively rare that all survive; while in quadruplets premature 
labor and the death of the fetuses are almost certain. It is a common 
observation that twins are often unequally developed at birth. By some 
this difference is attributed to one of them being of a different age to the 
other. It is probable, however, that in most of these eases the lull 
development of one fetus has been interfered with by pressure of the 
other. This is flu* from uncommonly carried to the extent of destroying 
one of the twins, which is expelled at term, mummified and flattened 
between the living child and the uterine wall. In other cases, when one 
foetus dies it may be expelled without terminating the pregnancy, the 
other being retained in utero and born at term; and those who dis- 
believe in the possibility of superfcetation explain in this way the cases 
in which it is believed to have occurred. 

('(/uses. — Multiple pregnancies depend on various causes. The most 
common is probably the .simultaneous, or nearly simultaneous, matura- 
tion and rupture of t\\<> Graafian follicles, the ovules becoming impreg- 
nated at or about the same time. It by no mean- necessarily follows, 
even it* more than one follicle should rupture at once, that both ovules 
should be impregnated. This is proved by the occurrence of cases in 

1 On Fecundity, Fertility, and Sterility, p. 99. 2 Obst. Trans., vol xi. 

:i Obst. Works, p. 830. 



168 PREGNANCY. 

which there are two corpora lutea with only one foetus. There are 
numerous facts to prove that ovules thrown off within a short time of 
each other may become separately impregnated, as in cases in which 
negro women have given birth to twins, one of which was pure negro, 
the other half-caste. 

It may happen, however, that a single Graafian follicle contains more 
than one ovule, as has actually been observed before its rupture ; or, as 
is not uncommon in the egg of the fowl, an ovule may contain a double 
germ, each of which may give rise to a separate foetus. 

Arrangement of the Foetal Membranes and Placenta?. — The various 
modes in which twins may originate explain satisfactorily the variations 
which are met with in the arrangement of the foetal membranes and in 
the form and connections of the placentas. In a large proportion of 
cases there are two distinct bags of membranes, the septum between 
them being composed of four layers — viz. the chorion and amnion of 
each ovum. The placentae are also entirely separate. Here it is obvi- 
ous that each twin is developed from a distinct ovum, having its own 
chorion and amnion. On arriving in the uterus it is probable that each 
ovum becomes fixed independently in the mucous membrane and is sur- 
rounded by its own decidua reflexa. As growth advances the decidua 
reflexa generally atrophies from pressure, as it is not usual to find more 
than four layers of membrane in the septum separating the ova. In 
other cases there is only one chorion, within which are two distinct 
amnions, the septum then consisting of two layers only. Then the 
placentae are generally in close apposition and become fused into a single 
mass, the cords, separately attached to each foetus, not infrequently unit- 
ing shortly before reaching the placental mass, their vessels anastomosing 
freely. In other more rare instances both foetuses are contained in a 
common amniotic sac ; but as the amnion is a purely foetal membrane, 
it is probable that, when this arrangement is met with, the originally 
existing septum between the amniotic sacs has been destroyed. In both 
these latter cases the twins must have been developed from a single 
ovule containing a double germ, and Schroeder states that they are then 
always of the same sex. Dr. Brunton 1 has started a precisely opposite 
theory, and has tried to prove that twins of the same sex are contained 
in separate bags of membrane, while twins of opposite sexes have a com- 
mon sac. He says that out of 25 cases coming under his observation, 
in 15 the children contained in different sacs were of the same sex, but 
in the remaining 10, in which there was only one sac, they were of 
opposite sexes. It is difficult to believe that there is not an error in 
these observations, since twins contained in a single amniotic sac do not 
occur nearly as often as ten times out of twenty-five cases, and no dis- 
tinction is made between a common chorion with two amnions and a 
single chorion and amnion. The facts of double monstrosity also dis- 
prove this view, since conjoined twins must of necessity arise from a 
single ovule with a double germ, and there is no instance on record in 
which they were of opposite sexes. 

Membranes and Placenta? in Triplets. — In triplets the membranes and 
placentae may be all separate, or, as is commonly the case, there is one 

1 Obat. Trans., vol. x. 



ABNORMAL PREGNANCY. 169 

complete bag of membranes, and a second having a common chorion, 
with a double amnion. It is probable, therefore, that triplets are gen- 
erally developed from two ovules, one of which contained a double germ. 

Diagnosis of Multiple Pregnancy. — It is comparatively seldom that 
twin pregnancy can be diagnosed before the birth of the first child, and 
even when suspicion has arisen its indications are very defective. There 
is generally an unusual size and an irregularity of shape of the uterus, 
sometimes even a distinct depression or sulcus between the two fcetuses. 
When such a sulcus exists, it may be possible to make out parts of each 
fcetus by palpation on either side of the uterus. The only sign, how- 
ever, on which the least reliance can be placed is the detection of two 
fcetal hearts. If two distinct pulsations are heard at different parts of 
the uterus ; if, on carrying the stethoscope from one point to another, 
there is an interspace where pulsations are no longer audible, or when 
they become feeble and again increase in clearness as the second point is 
reached ; and, above all, if we are able to make out a difference in fre- 
quency between them, — the diagnosis is tolerably safe. It must be 
remembered, however, that the sounds of a single heart may be heard 
over a larger space than usual, and hence a possible source of error. 
Twin pregnancy, moreover, may readily exist without the most careful 
auscultation enabling us to detect a double pulsation, especially if one 
child lie in the dorso-posterior position, when the body of the other may 
prevent the transmission of its heart's beat. The so-called placental 
souffle is generally too diffuse and irregular to be of any use in diagnosis 
even when it is distinctly heard at separate parts of the uterus. 

Superfcetation and Superfecundation. — Closely connected with the sub- 
ject of multiple pregnancies are the conditions known as superfeounda- 
t/on and superfcetation, regarding which there has been much controversy 
and difference of opinion. 

By the former is meant the fecundation, at or near the same period of 
time, of two separate ovules before the decidua lining the uterus has 
been formed, which by many is supposed to form an insuperable obsta- 
cle to subsequent impregnation. The possibility of this occurrence has 
been incontestable proved by the class of cases already referred to, in 
which the same woman has given birth to twins bearing evident traces 
of being the offspring of fathers of different races. 

By superfcetation is meant the impregnation of a second ovule, when 
the uterus already contains an ovum which has arrived at a considerable 
degree of development. The cases which are supposed to prove the pos- 
sibility of this occurrence are very numerous. They are those in which 
a woman is delivered simultaneously of fetuses of very different ages, 
one hearing all the marks of having arrived at term, the other of pre- 
maturity; or of those in which a woman is delivered of an apparently 
mature child, and, after the lapse of a few months, of another equally 
mature. The possibility of superfcetation is strongly denied by many 
practitioners of eminence, and explanations are given which doubtless 
seem to account satisfactorily for a large proportion of the supposed 
examples. In the former class of cases it is supposed, with much proba- 
bility, that there is an ordinary twin pregnancy, the development of one 
foetus being retarded by the presence in utero of another. Thai ilii- is 



170 PREGNANCY. 

not an uncommon occurrence is certain, and the fact has already been 
alluded to in treating of twin pregnancy. In cases of the latter kind it 
is possible that some of them may be due to separate impregnation in a 
bilobed uterus, the contents of one division being thrown off a consider- 
able time before those of the other. JSumerous authentic examples of 
this occurrence are recorded, but by far the most remarkable is that 
related by Dr. Eoss of Brighton, which has been already referred to 
(p. 67). In this case the patient had previously given birth to many 
children without any suspicion of her abnormal formation having arisen, 
and, had it not been detected by Dr. Ross, the case might fairly enough 
have been claimed as an indubitable example of superfoetation. 

Making every allowance for these explanations, there remain a con- 
siderable number of cases which it is very difficult to account for, except 
on the supposition that the second child has been conceived a consider- 
able time after the first. Those interested in the subject will find a large 
number of examples collected in a valuable paper by Dr. Bonnar of 
Cupar. 1 He has adopted the ingenious plan of consulting the records 
of the British peerage, where the exact date of the birth of successive 
children of peers is given, without, of course, any reasonable possibility 
of error, and he has collected numerous examples of births rapidly suc- 
ceeding each other which are apparently inexplicable on any other 
theory. In one case he cites a child was born September 12, 1849, and 
the mother gave birth to another on January 24, 1850, after an interval 
of only 127 days. Subtracting from that 14 days, which Dr. Bonnar 
assumes to be the earliest possible period at which a fresh impregnation 
can occur after delivery, we reduce the gestation to 113 days — that is, to 
less than four calendar months. As both these children survived, the 
second child could not possibly have been the result of a fresh impregna- 
tion after the birth of the first ; nor could the first child have been a twin 
prematurely delivered, for if so, it must have only reached rather more than 
the fifth month, at which time its survival would have been impossible. 

Besides the numerous examples of cases of this kind recorded in most 
obstetric works, there are one or two of miscarriage in the early months, 
in which, in addition to a foetus of four or five months' growth, a per- 
fectly fresh ovum of not more than a month's development was thrown 
off. One such case was shown at the Obstetrical Society in 1862, which 
was reported on by Drs. Harley and Tanner, who stated that in their 
opinion it was an example of superfoetation. A still more conclusive 
case is recorded by Tyler Smith : 2 " A young married woman, pregnant 
for the first time, miscarried at the end of the fifth month, and some 
hours afterward a small clot was discharged, enclosing a perfectly 
healthy ovum of about one month. There were no signs of a double 
uterus in this case. The patient had menstruated regularly during the 
time she had been pregnant. " This case is of special interest from the 
fact of the patient having menstruated during pregnancy — a circum- 
stance only explicable on the same anatomical grounds which render 
superfoetation possible. So far as I know, it is the only instance in 
which the coincidence of superfoetation and menstruation during early 
pregnancy has been observed. 

1 Edin. Med. Journ., 1864-65. 2 Manual of Obstetrics, p. 112. 



ABNORMAL PREGNANCY. 



171 



Objections to the Admission of Superfoetation. — The objections to the 
possibility of superfoetation are based on the. assumptions that the 
decidua so completely fills up the uterine cavity that the passage of the 
spermatozoa is impossible ; that their passage is prevented by the mucous 
plug which blocks up the cervix ; and that when impregnation has taken 
place ovulation is suspended. It is, however, certain that none of these 
are insuperable obstacles to a second impregnation. The first was orig- 
inally based on the older and erroneous view which considered the de- 
cidua to be an exudation lining the entire uterine cavity and sealing up 
the mouths of the Fallopian tubes and the aperture of the internal os 
uteri. The decidua reflexa, however, does not come into apposition with 
the decidua vera until about the eighth week of pregnancy, and, there- 
fore, until that time there is a free space between the two membranes 
through which the spermatozoa might pass to the open mouths of the 
Fallopian tube, and in which a newly-impregnated ovule might graft 
itself. A reference to the accompanying figure of a pregnancy in the 
third month, copied from Coste's work, will readily show that, as far as 
the decidua is concerned, there is no mechanical obstacle to the descent 
and lodgment of another impregnated ovule (Fig. 80). Then, as regards 

Fig. 80. 




Illustrating the Cavity between the Decidua Vera and the Decidua Reflexa during the Early 
Months of Pregnancy. (After Coste.) 

the plug of mucus, it is pretty certain that this i- in no way differenl 
from the mucus filling the cervix in the non-pregnant state, which <»n'<T- 
no obstacle at all to the passage of the spermatozoa. Lastly, respecting 
the cessation of ovulation during pregnancy, this, no doubt, is the rule, 
and probably satisfactorily explains the rarity of superfoetation. There 
are, however, a sufficient number of authenticated cases of menstruation 
during pregnancy to prove that ovulation is not always absolutely in 



172 PREGNANCY. 

abeyance ; and, as long as it occurs, there is unquestionably no positive 
mechanical obstruction, at least in the early months of pregnancy, in the 
way of the impregnation and lodgment of the ovules that are thrown 
off. The reasonable conclusion, therefore, seems to be that, although a 
large majority of the supposed cases are explicable in other ways, it can- 
not be admitted that superfcetation is either physiologically or mechani- 
cally impossible. 

Extra-uterine Pregnancy. — The most important of the abnormal vari- 
eties of pregnancy, if we consider the serious and very generally fatal 
results attending it, is the so-called extra-uterine foetation, which consists 
in the arrest and development of the ovum outside the cavity of the 
uterus. Of late years this subject has received much well-merited atten- 
tion, which, it is to be hoped, may lead to the establishment of some 
definite rules for the management of this most anxious and dangerous 
class of cases. 

Site of Extra-uterine Pregnancy. — The ovum may be arrested and 
developed in various situations on its way to the uterus, most commonly 
in some part of the Fallopian tube, or it may be in the cavity of the 
abdomen, or even quite beyond it, as in a few rare cases in which the 
ovum has found its way into a hernial sac. 

Classification. — Extra-uterine gestation may be subdivided into the 
following classes : 1st, and most common of all, Tubal gestation, and, as 
varieties of this, although by some made into distinct classes, (a) inter- 
stitial and (b) tubo-ovarian gestation. In the former of these subdivis- 
ions the ovum is arrested in the part of the Fallopian tube that is situ- 
ated in the substance of the uterine parietes ; in the latter, at or near 
the fimbriated extremity of the tube, so that part of its cyst is formed 
by the tube and part by the ovary. 2d. Abdominal gestation, in which 
an ovum, instead of finding its way into the tube, falls into the peri- 
toneal cavity, and there becomes attached and developed ; or the so-called 
secondary abdominal gestation, in which an extra-uterine pregnancy, 
originally tubal, becomes ventral through rupture of its cyst and escape 
of its contents into the abdominal cavity. 3d. Ovarian gestation, the 
existence of which is denied by many writers of eminence, such as Vel- 
peau and Arthur Farre, while it is maintained by others of equal celeb- 
rity, such as Kiwisch, Coste, and Hecker. It must be admitted that it 
is extremely difficult to understand how an ovarian pregnancy, in the 
strict sense of the word, can occur, for it implies that the ovule has be- 
come impregnated before the laceration of the Graafian follicle, through 
the coats of which the spermatozoa must have passed. Coste, indeed, 
believes that this frequently happens ; but, while spermatozoa have been 
detected on the surface of the ovary, their penetration into the Graafian 
follicle has never been demonstrated. Farre has also clearly shown that 
in many cases of supposed ovarian pregnancy the surrounding structures 
were so altered that it was impossible to trace their exact origin and to 
say to a certainty that the foetus was really within the substance of the 
ovary. Kiwisch gives a reasonable explanation of these cases by sup- 
posing that sometimes the Graafian follicle may rupture, but that the 
ovule may remain within it without being discharged. Through the 
rent in the walls of the follicle the spermatozoa may reach and impreg- 



ABNORMAL PREGNANCY. 173 

nate the ovule, which may develop in the situation in which it has been 
detained. The subject has been recently ably considered by Puech, 1 who 
admits two varieties of ovarian pregnancy, according as the foetus has 
developed in a vesicle which has remained open or in one which has 
closed immediately after fecundation. He considers that most cases of 
so-called ovarian pregnancy are either dermoid cysts, ovario-tubal preg- 
nancies, or abdominal pregnancies in which the placenta is attached to 
the ovary, and that even in the rare cases of true ovarian pregnancies 
the progress and results do not differ from those of abdominal preg- 
nancy. While, therefore, it is impossible to deny the existence of ova- 
rian pregnancy, it must be considered to be a very rare and exceptional 
variety, which, as far as treatment and results are concerned, does not 
differ from tubular or abdominal gestation. 4th. There are two rare 
varieties in which an ovum is developed either in the supplementary 
horn of a bilobed uterus or in a hernial sac. 

For the sake of clearness, we may place these varieties of extra-ute- 
rine gestation in the following tabular form : 

1st. Tubal— 

(a) Interstitial, (b) Tubo-ovarian. 

2d. Abdominal — 

(a) Primary, (b) Secondary. 

3d. Ovarian. 

4th. In bilobed uterus, hernial, etc. 

Causes. — The etiology of extra-uterine fcetation in any individual case 
must necessarily be almost always obscure. Broadly speaking, it may 
be said that extra-uterine fetation may be produced by any condition 
which prevents or renders difficult the passage of the ovule to the ute- 
rus, while it does not prevent the access of the spermatozoa to the ovule. 
Thus, inflammatory thickening of the coats of the Fallopian tubes by 
lessening their calibre, but not sufficiently so to prevent the passage of 
the spermatozoa, may interfere with the movements of the tube which 
propel the ovum forward, and so cause its arrest. A similar effect 
may be produced by various morbid conditions, such as inflammatory 
adhesions from old-standing peritonitis pressing on the tube, obstruc- 
tion of its calibre by inspissated mucus or small polypoid growths, the 
pressure of uterine or other tumors, and the like. The fact that extra- 
uterine pregnancies occur most frequently in multiparas, and compara- 
tively rarely in women under thirty years of age, tends to show that 
these conditions, which are clearly more likely to be met with in such 
women than in young primiparae, have considerable influence in its 
causation. A curiously large proportion of cases occur in women who 
have either been previously altogether sterile or in whom a long interval 
of time has elapsed since their last pregnancy. The disturbing effects 
of fright, either during coition or a few days afterward, have hen 
inn-ted on by many authors as a possible cause. Numerous cases of 
this kind are recorded; and, although the influence of emotion in the 
production of this condition is not susceptible of proof, it is not difficult 
to imagine that spasms of the Fallopian tube- might be produced in this 
way which would either interfere with the passage of the ovum or direct 

1 Annal. de Gynec, July, 1878. 



174 PREGNANCY. 

it into the abdominal cavity. The occurrence of abdominal pregnancy 
is probably less difficult to account for if we admit, with Coste, that the 
ovule becomes impregnated on the surface of the ovary itself, for there 
must be very many conditions which prevent the proper adaptation of 
the fimbriated extremity of the tube to the surface of the ovary, and 
failing this the ovum must of necessity drop into the abdominal cavity. 
Kiwisch has pointed out that this is particularly apt to occur when the 
Graafian follicle develops on the posterior surface of the ovary ; and, 
indeed, it is probable that it may be of common occurrence, and that 
the comparative rarity of abdominal pregnancy is due to the difficulty 
with which the impregnated ovule engrafts itself on the surrounding 
viscera. Impregnation may actually occur in the abdominal cavity 
itself, of which Keller 1 relates a remarkable instance. In this case 
Koeberle had removed the body of the uterus and part of the cervix, 
leaving the ovaries. In the portion of the cervix that remained there 

Fig. 81. 




Tubal Pregnancy, with the Corpus Luteum in the Ovary on the opposite side. 
The decidua is represented in the process of detachment from the uterine cavity. 

was a fistulous aperture opening into the abdominal cavity through 
which semen passed and produced an abdominal gestation. Several 
curious cases are also recorded, which have given rise to a good deal 
of discussion, in which a tubal pregnancy existed while the corpus 
luteum was on the opposite side (Fig. 81). The most probable explana- 
tion, however, is that the fimbriated extremity of the tube in which the 
ovum was found had twisted across the abdominal cavity and grasped 
the opposite ovary, in this way, perhaps, producing a flexion which 
impeded the progress of the ovum it had received into its canal. Tyler 
Smith suggested that such cases might be explained by supposing that 
the ovum, after reaching the uterus, failed to graft itself in the mucous 
membrane, but found its way into the opposite Fallopian tube. Kuss- 
maul 2 thinks that such a passage of the ovum across the uterine cavity 
may be caused by muscular contraction of the uterus, occurring shortly 
after conception, squeezing the yet free ovum upward toward the open- 
ing of the opposite tube, and possibly into the tube itself. 

The history and progress of cases of extra-uterine pregnancy are mate- 

1 Des Grossesses Fxlra-uterines, Paris, 1872. 2 Mon.f. Geburt, Oct., 1862. 



ABNORMAL PREGNANCY. 



175 



rially different according to their site, and, for practical purposes, we may 
consider them as forming two great classes, the tubal (with its varieties) 
and the abdominal. 

Tubal Pregnancies. — When the ovum is arrested in any part of the 
Fallopian tube, the chorion soon commences to develop villi, just as in 
ordinary pregnancy, which engraft themselves into the mucous lining 
of the tube and fix the ovum in its new position. The mucous mem- 
brane becomes hypertrophied, much in the same way as that of the 
uterus under similar circumstances, so that it becomes developed into 
a sort of pseudo-decidua. Inasmuch, however, as the mucous coat of 
the tubes is not furnished with tubular glands, a true decidua can 
scarcely be said to exist, nor is there any growth of membrane around 
the ovum analogous to the decidua reflexa. The ovum is therefore, 
comparatively speaking, loosely attached to its abnormal situation, and 
hence hemorrhage from laceration of the chorion villi can very readily 
take place. 

It is seldom that any development of the chorion villi into distinct 
placental structure is observed ; this is probably owing to the fact that 
laceration and death generally occur before the period at which the 
placenta is normally formed. The muscular coat of the tube soon 
becomes hypertrophied, and as the size of the ovum increases the 
fibres are separated from each other, so that the ovum protrudes at 

Fig. 82. 




Tubal Pregnancy. (From a Specimen in the Museum of King's Coll 

certain points through them, and at these it is only covered by the 
stretched and attenuated mucous and peritoneal coats of the tube. At 
this time the tubal pregnancy forms a smooth oval tumor, which, as 
a rule, has not formed any adhesions to the surrounding structures 
(Fig. 82). The part of the tube unoccupied by the ovum may be 



176 PREGNANCY. 

found unaltered, and permeable in both directions ; or, more frequently, 
it becomes so stretched and altered that its canal cannot be detected. 
Most frequently it is that part of the tube nearest the uterus which 
cannot be made out. The condition of the uterus in this as in other 
forms of extra-uterine pregnancy has been the subject of considerable 
discussion. It is now universally admitted that the uterus undergoes 
a certain amount of sympathetic engorgement, the cervix becomes soft- 
ened, as in natural pregnancy, and the mucous membrane develops into 
a true decidua. In many cases the decidua is found on post-mortem 
examination, in others it is not, and hence the doubts that some have 
expressed as to its existence. The most reasonable explanation of its 
absence is that given by Duguet, 1 who has shown that it is far from 
uncommon for the uterine decidua to be thrown off en masse during the 
hemorrhagic discharges which so frequently precede the fatal issue of 
extra-uterine gestation. 

Interstitial and False Ovarian Pregnancy. — When the ovum is arrested 
in that portion of the tube passing through the uterus in so-called inter- 
stitial pregnancy, the muscular fibres of the uterus become stretched and 
distended, and form the outer covering of the ovum. When, on the 
other hand, the site of arrest is in the fimbriated extremity of the tube, 
the containing cyst is" formed partly of the fimbriae of the tube, partly 
of ovarian tissue ; hence it is much more distensible, and the pregnancy 
may continue without laceration to a. more advanced period, or even to 
term, so that when the ovum is placed in this situation the case much 
more nearly resembles one of abdominal pregnancy. 

Period at which Rupture occurs. — The termination of tubal pregnancy, 
in the immense majority of cases, is death, produced by laceration giving 
rise either to internal hemorrhage or to subsequent intense peritonitis. 
Rupture usually occurs at an early period of pregnancy, most generally 
from the fourth to the twelfth week, rarely later. However, a few 
instances are recorded in which it did not take place until the fourth or 
fifth month, and Saxtorph and Spiegelberg have recorded apparently 
authentic cases in which the pregnancy advanced to term without lacera- 
tion. It is generally effected by distension of the tube, which at last 
yields at the point which is most stretched ; and sometimes it seems to 
be hastened or determined by accidental circumstances, such as a blow 
or fall or the excitement of sexual intercourse. 

Symptoms of Rupture. — The symptoms accompanying rupture are 
those of intense collapse, often associated with severe abdominal pain, 
produced by the laceration of the cyst. The patient will be found 
deadly pale, with a small, thready, and almost imperceptible pulse, per- 
haps vomiting, but with mental faculties clear. If the hemorrhage be 
considerable, she may die without any attempt at reaction. Sometimes, 
however — and this generally occurs in cases in w r hich the tube tears, the 
ovum remaining intact — the hemorrhage may cease on account of the 
ovum protruding through the aperture and acting as a plug. The patient 
may then imperfectly rally, to be again prostrated by a second escape of 
blood, which proves fatal. If the loss of blood is not of itself sufficient 
to cause death from shock and ansemia, the fatal issue is generally only 

1 Annates de Gijnecologie, May, 1874. 



ABNORMAL PREGNANCY. 



177 



postponed, for the effused blood soon sets up a violent general peritonitis, 
which rapidly carries off the patient. If she should survive the second 
danger, the case is transformed into one of abdominal pregnancy, the 
foetus becoming surrounded by a capsule produced by inflammatory exu- 
dation (Fig. 83). The case is then subjected to the rules of treatment 




Extra-uterine Pregnancy at Term of the Tubo-ovarian Variety, 

Dr. A. Sibley Campbell's.) 



(After a Case of 



presently to be discussed when considering that variety of extra-uterine 
gestation. 

Diagnosis. — The possibility of diagnosing tubal gestation before rup- 
ture occurs is a question of great and increasing interest, from the faci 
that, could its existence be ascertained, we might very fairly hope to 
avert the almost certainly fatal issue which is awaiting the patient. Un- 
fortunately, the symptoms of tubal pregnancy are always obscure, and too 
often death occurs without the slightest suspicion as to the nature of the 
case having arisen. In the first place, it is to be observed that all the 
usual sympathetic disturbances of pregnancy exist : the breasts enlarge, 
the areolae darken, and morning sickness is present. There is also an 
arrest of menstruation, but after the absence of one or more periods 
there is often an irregular hemorrhagic discharge. This is an important 
symptom, the value of which in indicating the existence of tubal preg- 
nancy has of late years been much dwelt upon by various author.-, both 
12 



178 PREGNANCY. 

in this country and abroad. Barnes attributes it to partial detachment 
of the chorion villi, produced by the ovum growing out of proportion to 
the tube in which it is contained. Whether this is the correct explana- 
tion or not, it is a fact that irregular hemorrhage very generally precedes 
the laceration for several days or more. Accompanying this hemorrhage 
there is almost always more or less abdominal pain, produced by the 
stretching of the tissues in which the ovum is placed, and this is some- 
times described as being of a very intense and crampy character. If, then, 
we meet with a case in which the symptoms of early pregnancy exist, in 
which there are irregular losses of blood, possibly discharge of mem- 
branous shreds, and abdominal pain, a careful examination should be 
insisted on, and then the true nature of the case may possibly be ascer- 
tained. Should extra-uterine foetation exist, we should expect to find 
the uterus somewhat enlarged and the cervix softened, as in early preg- 
nancy, but both these changes are doubtless generally less marked than 
in normal pregnancy. This fact, of itself, however, is of little diag- 
nostic value, for slight differences of this kind must always be too 
indefinite to justify a positive opinion. 

Presence of a Peri-uterine Tumor. — The existence of a peri-uterine 
tumor, rounded or oval in outline, and producing more or less displace- 
ment of the uterus in the direction opposite to that in which the tumor 
is situated, may point to the existence of tubular foetation. By bi- 
manual examination, one hand depressing the abdominal wall, while the 
examining finger of the other acts in concert with it either through the 
vagina or rectum, the size and relations of the growth may be made out. 
There are various conditions which give rise to very similar physical 
signs, such as small ovarian or fibroid growths or the effusion of blood 
around the uterus ; and the differential diagnosis must always be very 
difficult, and often impossible. A curious example of the difficulty of 
diagnosis is recorded by Joulin, in which Huguier and six or seven of 
the most skilled obstetricians of Paris agreed on the existence of extra- 
uterine pregnancy, and had, in consultation, sanctioned an operation, 
Avhen the case terminated by abortion, and proved to be a natural preg- 
nancy. The use of the uterine sound, which might aid in clearing up 
the case, is necessarily contraindicatecl unless uterine gestation is certainly 
disproved. Hence it must be admitted that positive diagnosis must 
always be very difficult. So that the most we can say is, that when 
the general signs of early pregnancy are present, associated with the 
other symptoms and signs alluded to, the suspicion of tubal pregnancy 
may be sufficiently strong to justify us in taking such action as may 
possibly spare the patient the necessarily fatal consequence of rupture. 

Treatment. — If the diagnosis were quite certain, the removal of the 
entire Fallopian tube and its contents by abdominal section would be 
quite justifiable, and probably would neither be more difficult nor more 
dangerous than ovariotomy ; for, at this stage of extra-uterine foetation, 
there are no adhesions to complicate the operation. As yet, however, the 
uncertainty of the diagnosis has prevented the adoption of the practice. 

Opening of the Sae by the Galvano-caustic Knife. — Dr. Thomas of 
New York 1 has recently recorded a most instructive case, in which he 
1 New York Med. Journ., June, 1875. 



ABNORMAL PREGNANCY. 179 

saved the life of the patient by a bold and judicious operation. The 
nature of the case was rendered pretty evident by the signs above 
described, and Thomas opened the cyst from the vagina by a platinum 
knife rendered incandescent by a galvano-caustic battery, by which 
means he hoped to prevent hemorrhage. Through the opening thus 
made he removed the foetus. In subsequently attempting to remove 
the placenta very violent hemorrhage took place, which was only arrested 
by injecting the cyst with a solution of persulphate of iron. The remains 
of the placenta subsequently came away piecemeal, after an attack of 
septicaemia, which was kept within bounds by freely washing out the 
cyst with antiseptic lotion, the patient eventually recovering. If I 
might venture to make a criticism on a case followed by so brilliant 
a success, it would be that in another instance of this kind it would be 
safer to follow the rule so strictly laid down with regard to gastrotomy 
in abdominal pregnancies, and leave the placenta untouched, trusting 
to the injection of antiseptics and the thorough drainage of the cyst to 
prevent mischief^ 1 ] 

[The advice given by the author in regard to the non-removal of the 
placenta was first urged upon the medical profession in 1791 by Mr. 
William Trumbull in a paper read before the Medical Society of London, 
and again in 1795, in a letter 2 from the late Dr. James Mease of Phila- 
delphia to Dr. Lettsom of London, in which he reported an operation 
by Dr. Charles McKnight of New York very similar to this of Dr. 
Thomas, and ending favorably to the woman. The remarks of Dr. 
Mease on the impropriety of removing the placenta were read before the 
same society, and concurred in by some of the members present. 

It is a little remarkable that the opinion of Dr. Mease originated in 
an accident which occurred in the operation of Dr. McKnight, by which 
the funis was ruptured, and in consequence of which the placenta, which 
was outside of the cyst, could not be found for removal. The value of 
this discovery appears to have been lost to the profession for a long term 
of years, as many authors have objected to the operation because of the 
danger of removing the placenta. 

In a second operation, performed on May 10, 1876, in a case of 
secondary abdominal pregnancy, Dr. Thomas 3 operated through the 
linea alba, and removed a female foetus weighing 6 lbs. lo oz. 
The funis was traced to the left iliac fossa, where it was apparently 
inserted into the peritoneum, and no placenta was discernible. The 
cord was cut off at its origin, and the wound closed, except at its lower 
part, which was kept open by a glass tube. The woman's pulse before 
the operation was 120, and fell to 107 at the end of the firsl week ; 
temperature was always 100° and upward, but in the middle of the 

[' Dr. J. H. Mathieson of St. Mary's, Ontario, performed a similar operation on .June 
28, 1 881, and, as in the King case of Edisto Island in 1816, saved both mother and 
foetus. The subject was a woman of 30, and pregnant for the sixth time. After open- 
ing the vagina the foetus, which weighed 8 Ihs. 7.' oz., was delivered by the forceps. 
The placenta, which was three-lobed, was easily peeled oil; and a sponge soaked with 
solution of perchloride of iron was inserted. There was not much hemorrhage, and 
the cyst was treated with antiseptic syringing. It was three months in closing up 
(Trails. Obstetric Soc. London, May 7. 1884; Lancet, May 24, L884, p. 940). —Ed.] 

[ a Memoirs of Med. Soc. London, vol. iv. p. 342, 1.795.] 

[ 3 Am. Journ. of Obstetrics, vol. ix. p. 655, 1876.] 



180 PREGNANCY. 

fourth week it rose to 103°-104°, and the pulse to 130. The placenta 
was found presenting at the opening in the abdomen, and was removed 
with dressing forceps. It was of the ordinary diameter and had a 
shrivelled appearance. The removal afforded a decided relief, and the 
temperature fell within three hours. Antiseptic injections were freely 
used in the treatment of the case, and the patient made a good re- 
covery. 

Prof. T. Gaillard Thomas, above referred to, has reported 1 27 cases of 
extra- uterine pregnancy which have come under his personal observation, 
all but 3 of them having been seen in consultation. Of these, 17 re- 
covered and 10 died. Rupture of the sac occurred in 7 cases, with 6 
deaths. Laparotomy Was performed in 5 cases, 4 of which recovered. 
In 2 women the cysts were tapped, and both died. One cyst was incised 
by the thermo-cautery per vaginam, with recovery, and one was evacu- 
ated per rectum, but the patient died. Two recovered after spontaneous 
evacuation by the rectum, and 3 were cured by destroying the foetus 
under galvanism. Prof. Goodell of Philadelphia reports 13 cases, with 
3 recoveries. 2 — Ed.] 

Means of Destroying the Vitality of the Foetus. — Another mode of 
managing these cases is to destroy the foetus, so as to check its further 
growth, in the hope that it may. remain inert and passive within its sac. 
Various operations have been suggested and practised for this purpose. 
Thus, needles have been introduced into the tumor, through which 
currents of electricity have been passed, either the continuous current, 
or, as has been suggested by Duehenne, a spark of Franklinic electricity. 
Hicks, Allen, and others have endeavored to destroy the foetus by 
passing an electro-magnetic current through it by means of a needle. [ 3 ] 
Lusk 4 relates several successful cases following the use of the faradic 
current, one pole being passed through the rectum to the site of the 
ovum, the other being placed on a point in the abdominal wall two or 
three inches above Poupart's ligament. The current should be passed 
daily for five or ten minutes, and continued for a week or two until the 
shrinking of the tumor gives satisfactory evidence of the death of the 
foetus. In a case reported by Dr. Bachetti, in which the continuous 
current was used, the growth of the ovum was arrested and the patient 
recovered. The same result, however, would probably have followed 
the simple puncture of the cyst. This has been successfully practised 
on several occasions, either with a small trocar and canula or with a 
simple needle. A very interesting case, in which the development of a 
two months' tubal gestation was arrested in this way, is recorded by 
Greenhalgh, 5 and another by Martin of Berlin 6 . Joulin suggested that 
not only should the cyst be punctured, but that a solution of morphia 
should be injected into it, which, by its toxic influence, would ensure the 
destruction of the foetus ; and this is probably one of the best means at 
our disposal for destroying the foetus. Other means proposed for effect- 
ing the same object, such as pressure or the administration of toxic 

[} Tram. Am. GyncecoJ. Soc, vol. vii., for 1882. and vol. ix., for 1884.] [ 2 Ibid.] 
[ 3 Dr. Allen did not use needles in applying the current. — Ed.] 

4 Science and Art of Midwifery, p. 321. 

6 Lancet, 1867. 6 Monat.f. Gcburt, 1868. 



ABNORMAL PREGNANCY. 181 

remedies by the mouth, are far too uncertain to be relied on. The 
simplest and most effectual plan would be to introduce the needle of 
an aspirator, by which the liquor amnii would be drawn off and the 
further growth of the foetus effectually prevented. Parry, 1 indeed, is 
opposed to this practice, and has collected several cases in which the 
puncture of the cyst was followed by fatal results, either from hemorrhage 
or septicaemia. In these, however, an ordinary trocar and canula were 
probably employed, which would necessarily admit air into the sac. It 
is difficult to imagine that a fine hair-like aspirating needle, rendered 
perfectly aseptic by carbolic acid, could have any injurious results ; and 
it could do no harm, even if an error of diagnosis had been made and 
the suspected extra-uterine fcetation turned out to be some other sort of 
growth. If the aspirator proves that an extra-uterine fcetation exists, 
then, if the cyst be of any considerable size, and the pregnancy ad- 
vanced beyond the second month, we might, if deemed advisable, 
resort to a more radical operation, such as that so successfully practised 
by Thomas. 

[The safest aud most successful of all the methods that have been 
employed for arresting the development of an extra-uterine foetus is that 
of the galvanic current, for the efficient use of which needles and punc- 
turing are not at all necessary. This operation has been more frequently 
reported in the United States than in any other country, and of 15 cases 
on record not one was fatal. Dr. Henry J. Garrigues of New York 
City thus describes his method of operating: 2 "I used a French one- 
cell apparatus, composed of two carbon plates and one zinc plate im- 
mersed in Bunsen's battery fluid (potass, bichrom. §ij ; acid sulphuric, 
concentr. f §iss ; aquse fluv. f ,!xj). The positive electrode, made of a 
large carbon plate, covered with cloth, was applied on the abdomen over 
the tumor. The negative electrode, consisting of one insulated brass 
stem, with knob, was introduced into the vagina and pressed up against 
the lower part of the tumor. The current was gradually increased to 
the limit of her endurance, but never enough to cause real pain." Two 
days later the pulsation of the tumor previously felt in the vagina had 
disappeared, and the tumor was less in size. The applications were made 
for ten minutes almost daily for two weeks. In sixteen days the tumor 
had diminished to the size of an English walnut. — Ed.] 

Treatment when Rupture has Occurred. — When the chance of arrest- 
ing the growth of a tubular fcetation has never arisen, and we first rec- 
ognize its existence after laceration has occurred and the patient is col- 
lapsed from hemorrhage, what course are we to pursue? Hitherto, all 
that ever has been done is to attempt to rally the patient by stimulants, 
and, in the unlikely event of her surviving the immediate effects of lace- 
ration, endeavoring to control the subsequent peritonitis, in the hope 
that the effused blood may become absorbed, as in pelvic hseniatocele. 
This is, indeed, a frail reed to rest upon, and when laceration of a tubal 
gestation, advanced beyond a month, has occurred, death has been tli<' 
most certain result. It is supposed by Bernutz — and his opinion is shared 
by Barnes— that rupture which does not prove fatal is probably not very 

1 Parry on Extra-uterine Piegnancy, p. 204. 
['-' Trans, Am. Qyncecol. Soc, vol. vii., lor 1882.] 



182 PREGNANCY. 

rare in the first few days of extra-uterine gestation, and that it is not an 
uncommon cause of certain forms of pelvic hematocele. It has more 
than once being suggested that it would be perfectly justifiable when 
laceration has occurred to perform gastrotomy, to sponge aAvay the 
effused blood, and to place a ligature around the lacerated tube and 
remove it with its contents. This would no doubt be a bold and heroic 
procedure, but no one who is acquainted with the triumphs of modern 
abdominal surgery can say that it Avould be either impossible or hopeless. 
The sponging out of effused blood from the abdominal cavity is an 
every-day procedure in ovariotomy, nor is there any apparent difficulty 
in ligaturing and removing the sac of the extra-uterine pregnancy, for, 
as a rule, there are no adhesions formed to the surrounding parts. The 
history of these cases shows that death does not generally folloAV rupture 
for some hours, so that there would be usually time for the operation, 
and the extreme prostration might be, perhaps, temporarily counteracted 
by transfusion. Pressure on the abdominal aorta, resorted to when the 
patient is first seen, might possibly be employed with advantage to check 
further hemorrhage until the question of operation is decided. We must 
remember that the alternative is death, and hence any operation which 
would afford the slightest hope of success would be perfectly justifiable. 
I cannot, therefore, agree with those who hold that because the chances 
of success are so small the operation should not be tried ; and I do not 
doubt that it will yet fall to the lot of some one by this means to snatch 
a patient from the jaws of death and still further to extend the successes 
of abdominal surgery. 

[This has already been done upon four occasions, thanks to the bold- 
ness and skill of Mr. Lawson Tait of Birmingham, who has operated 
five times, losing only the first patient. These operations bear the dates 
of Jan. 17, 1883; March 1, 1884; April 9, 1884; May 25, 1884; and 
June 5, 1884. 1 There was no later one up to October 1, 1884. Thus, 
in four consecutive months there were four Avomen saved from death 
by internal hemorrhage following rupture of Fallopian foetal cysts. In 
theory, this operation has long been viewed as giving promise of suc- 
cess. Promptness, boldness, and the advantage of an early rupture Avere 
the requisites ; but permission to operate and agreement in consultation 
upon the case presented were the obstacles to be overcome. I became 
fully convinced of the practicability of this measure in making an 
autopsy of a young married lady in 1856, in Avhom a cyst had burst 
at about the fourth Aveek, causing her death in twenty-three hours. In 
that day no one would have dared to operate in such a case, and, besides, 
all of the three physicians Avho saw her under the attack believed she 
was not pregnant, as she Avas menstruating. The history of the case, as 
gi\ T en to me, indicated to ray mind that there had been a rupture of the 
right Fallopian tube ; Avhich proved to be correct. In the last edition 
of this Avork I referred to a case upon which Prof. T. Gaillard Thomas 
of New York would have operated had he not been o\ T erruled by several 
physicians in consultation, who Avere doubtful of the correctness of his 
diagnosis and feared to have it tested under the knife. In another case 
in New York the patient was operated upon by Dr. Charles K. Briddon, 

\} British Med. Jmirn., June 23, 1884, p. 1250.] 



ABNORMAL PREGNANCY. 183 

but the delay in getting a consultation and the final consent of the family 
was fatal to her : she lived forty-seven hours, but never reacted. At 7 
p. M. she was pulseless and thought herself dying ; at 9 P. M. a consulta- 
tion was held, and at 9.30 a second, with a third consultant. Then the 
family had to consent, and thus hours of vital moment were lost. 1 This 
success of Mr. Tait will open the way for the performance of the opera- 
tion by others. — Ed.] 

Abdominal Pregnancy. — In the second of the two classes into which, 
for practical convenience, we have divided extra-uterine gestation, the 
ovum is developed in the abdominal cavity. It is as yet an open ques- 
tion whether in some cases the pregnancy is primarily abdominal or not. 
Barnes believes that it probably never is so, on account of the difficulty 
of admitting that so minute a body as the ovum should be able to fix 
itself on the smooth peritoneal surface. He therefore thinks that all 
abdominal pregnancies are primarily either tubal or ovarian, the sac in 
which they were contained having given way, and the ovum having 
retained its vitality through partial attachment to the original sac. This 
theory is opposed to that of the majority of writers,. and, although it 
may perhaps render the facts less difficult to understand, it is purely 
hypothetical. There is no evidence to show that in most cases there is 
an early laceration of a tubal or ovarian sac. That the chorion villi do 
graft themselves upon the surrounding peritoneum is certain, and is 
observed in all cases of abdominal gestation. It is not more difficult 
to imagine them doing this from their very first development than a 
little later; for it must be allowed that if such laceration does occur, in 
most cases it can only be when pregnancy is very slightly advanced. On 
the whole, therefore, it seems not unreasonable to admit the usual explana- 
tion of these cases, that the ovule, already impregnated, escaped the grasp 
of the Fallopian tube and fell into the abdominal cavity, where it rooted 
itself and developed. Some have, indeed, supposed that abdominal preg- 
nancy may occasionally arise in consequence of spermatozoa finding 
their way into the peritoneal cavity, and there meeting and impregnat- 
ing an ovule discharged from the Graafian follicle. Such an event one 
would suppose to be almost impossible, but Koeberle's case, already 
() noted, proves that it has actually occurred. The probability is that it 
is by no means rare for impregnated ovules to drop into the peritonea] 
cavity, and that the majority of those that do so perish without doing 
any harm. When they do survive, however, the chorion villi sprout, 
attach themselves to the surrounding structures, and eventually develop 
into a placenta. The mode in which the chorion villi arc attached, and 
the arrangement of the maternal blood-vessels, have never yet been 
worked out, and would form a very interesting subject for investigation. 
The precise seat of attachment varies, and the placenta has been found 
fixed to most of the abdominal viscera, either those contained in the 
pelvis proper, or it may be the intestines, or to the iliac fossa ; mosl 
frequently, apparently, the ovum finds its way into the retro-uterine 
cul-de-sac. 

Formation of a Oyd around the Ovum. — The subsequent changes vary 
much. In the large majority of cases the ovum produces considerable 

I 1 Metlir.nl NciVS, Pliila., Dec 1 5, 1883, p. 666.] 



184 PREGNANCY. 

irritation, resulting in the exudation of plastic material, which is thrown 
round it, so as to form a secondary cyst or capsule in which maternal 
vessels are largely developed, and which stretches, pari passu, with the 
growth of the ovum (Fig. 84). The density and strength of this cyst 
are found to be very different in different cases ; sometimes it forms a 
complete and strong covering to the ovum, at others it is very thin and 




Uterus and Foetus in a Case of Abdominal Pregnancy. 

only partially developed, but it is rarely entirely absent. As there is 
ample space for the development of the ovum, and as the secondary cyst 
generally stretches and grows along with it, most cases of abdominal 
pregnancy progress without any very remarkable symptoms, beyond 
occasional severe attacks of pain, until the full term of pregnancy has 
been reached. Sometimes, however, the cyst lacerates, and there is an 
escape of blood into the abdominal cavity, accompanied by more or less 
prostration and collapse, which may prove fatal, but from which the 
patient more generally rallies. The foetus, now dead, will remain in the 
abdomen, and will undergo changes and produce results similar to those 
which we shall presently describe as occurring in cases progressing to the 
full period. 

Pseudo-labor sometimes Comes on. — In most cases, at the natural 
termination of pregnancy a strange series of phenomena occur : pseudo- 
labor comes on, there are more or less frequent and strong uterine con- 
tractions, possibly an escape of blood from the vagina, the discharge of 
the broken-down uterine decidua, and even the establishment of lacta- 
tion. Sometimes the contractions of the abdominal muscles produced 
by this ineffective labor have been so strong as to cause the laceration 
of the adventitious cyst surrounding the foetus, and the escape of blood 
and liquor amnii into the abdominal cavity, with a rapidly fatal result. 
More frequently laceration does not occur, and the spurious labor-pains 
continue at intervals until the foetus dies, possibly from pressure, but 
more often from effusion of blood into the tissue of the placenta, and 
consequent asphyxia. Occasionally the foetus has apparently lived a 



ABNORMAL PREGNANCY. 



185 



considerable time, in some cases even for several months, after the nat- 
ural limit of pregnancy has been reached. 

Changes After the Death of the Foetus. — It is after the death of the 
fcetus that the dangers of abdominal pregnancy generally commence, and 
they are numerous and various. The subsequent changes that occur are 
well worthy of study. Occasionally the foetus has been retained for a 
length of time, even until the end of a long life, without producing any 
serious discomfort, and in many cases of this kind several normal preg- 
nancies and deliveries have subsequently taken place. Even when the 
extra-uterine gestation appears to be tolerated, and has remained a long 
time without producing any bad effects, serious symptoms may be sud- 
denly developed, so that no woman, under such circumstances, can be 
considered safe. The condition of these retained fcetuses varies much. 
Most commonly the liquor amnii is absorbed, the fcetus shrinks and dies, 
all its soft structures are changed into adipocere, and the bones only re- 
main unaltered. Sometimes this change occurs with great rapidity. I 
have elsewhere l recorded a case of extra-uterine fcetation in which at the 
full term of pregnancy the fcetus was alive, and the woman died in less 
than a year afterward. On post-mortem examination the foetus was 
found entirely transformed into a greasy mass of adipocere, studded 
with foetal bones, in which not a trace of any of the soft parts could be 
detected. On the other hand, the foetus may remain unchanged : in the 
Museum of the College of Surgeons there is one which was retained in 
the abdomen for fifty-two years, and which was found to be as fresh and 
unaltered as a new-born child. In other cases the sac and its contents 
atrophy and shrink, and calcareous matter is deposited in them, so that 
the whole becomes converted into a solid mass known as UthopaxUon 
(Fig. 85). The cases, however, in which the retention of the foetus 
gives rise to no mischief are quite excep- 
tional. Generally the foetus putrefies, and 
this may either immediately cause fatal peri- 
tonitis or septicaemia, or, as more commonly 
happens, secondary inflammation and sup- 
puration of the sac. Under the influence of 
the latter the sac opens externally, either 
directly at some point of the abdominal 
walls or indirectly through the vagina, the 
bowels, or even the bladder. Through the 
aperture or apertures thus formed (for there 
are often several fistulous openings) pus and 
the bones and other parts of the broken- 
down fetus are discharged ; and this may 
go on for months, and even years, until at 
last, if the patient's strength does not give 
way, the whole contents of the cv>( are ex- 
pelled, and recovery takes place. From 
various statistical observations it appear- il: 
that the chances of recovery are best when 
the cyst opens through the abdominal walls, next through the vagina or 

1 Obat. Trans., vol. vii. 



Fig. 85. 




Lithopsedion. 

;i preparation in tin' Mu» 

the College of Surgeons.) 



186 PREGNANCY. 

bladder, and that the foetus is discharged with most difficulty and danger 
when the aperture is formed into the bowel. At the best, however, the 
process is long, tedious, and full of danger ; and the patient too often 
sinks, during the attempt at expulsion, through the irritation and exhaus- 
tion produced by the abundant and long-continued discharge. 

Diagnosis. — The diagnosis of abdominal gestation is by no means so 
easy as might be thought, and the most experienced practitioners have 
been mistaken with regard to it. 

The most characteristic symptom, although this is not so common as 
in tubal gestation, is metrorrhagia combined with the general signs of 
pregnancy. Very severe and frequently-repeated attacks of abdominal 
pain are rarely absent, and should at once cause suspicion, especially if 
associated with hemorrhage and the discharge of a decidual membrane 
from the uterus. They are supposed by some to depend on intercurrent 
attacks of peritonitis, by which the foetal cyst is formed. Parry doubts 
this explanation, and attributes them partly to the distension of the cyst 
by the growing foetus, and partly to pressure on the surrounding struc- 
tures. On palpation the form of the abdomen will be observed to differ 
from that of normal pregnancy, being generally more developed in the 
transverse direction, and the rounded outline of the gravid uterus cannot 
be detected. When development has advanced nearly to term, the 
extreme distinctness with which the foetal limbs can be felt will arouse 
suspicion. Per vaginam, the os and cervix will be felt softened, as in 
ordinary pregnancy, but often displaced by the pressure of the cyst, and 
sometimes fixed by perimetritic adhesions ; either of these signs is of 
great diagnostic value. 

By bi-manual examination it may be possible to make out that the 
uterus is not greatly enlarged, and that it is distinctly separate from the 
bulk of the tumor ; these facts, if recognized, would of themselves dis- 
prove the existence of uterine gestation. The diagnosis, if the foetal 
limbs or heart-sounds could be detected, would be cleared up in any case 
by the uterine sound, which would show that the uterus was empty and 
only slightly elongated. But we must be careful not to resort to this 
test unless the existence of uterine gestation is positively disproved by 
other means. As, however, it places the diagnosis beyond a doubt, it 
should always be employed whenever operative procedure is in contem- 
plation. Quite recently I have seen a remarkable case which illustrates 
the importance of this rule. The case had been diagnosed as abdominal 
pregnancy by no less than six experienced practitioners, and was actually 
on the operating-table for the performance of laparotomy. As a precau- 
tion, having some doubts of the diagnosis, I suggested the passage of the 
sound, which entered into a gravid uterus, the case proving to be one 
of small ovarian tumor jammed down into Douglas's space and displa- 
cing the cervix forward. Had it not been for this precaution its true 
nature would certainly not have been detected. 

Treatment. — The treatment of abdominal gestation will always be a 
subject of anxious consideration, and there is much difference of opinion 
as to the proper course to pursue. It is pretty generally admitted that 
it is not advisable to adopt any active measures until the full term of 
development is reached. Puncturing the cyst, with the view of destroy- 



ABNORMAL PREGNANCY. 187 

ing the foetus and arresting its further growth, has been practised, but 
there are good grounds for rejecting it, for there is not the same immi- 
nent risk of death from rupture of the cyst as in tubal foetation ; and 
even if the destruction of the foetus could be brought about, there would 
still be formidable clangers from subsequent attempts at elimination or 
from internal hemorrhage. 

Question as to the Performance of Primary Gastrotomy. — When the 
full period has arrived, the child being still alive, as proved by auscul- 
tation, we have to consider whether it may not be advisable to perform 
gastrotomy before the foetus perishes, and so at least save the life of the 
child. There are few questions of greater importance and more difficult 
to settle. The tendency of medical opinion is rather in favor of immedi- 
ate operation, which is recommended by Velpeau, Kiwisch, Koeberle, 
Schroecler, and many other writers, whose opinion necessarily carries 
great weight. The arguments used in favor of immediate operation are, 
that while it affords a probability of saving the child, the risks to the 
mother, great though they undoubtedly are, are not greater than those 
which may be anticipated by delay. If we put off interference, the cyst 
may rupture during the ineffectual efforts at labor, and death at once 
ensue ; or, if this does not take place, other risks, which can never be 
foreseen, are always in store for the patient. She may sink from peri- 
tonitis, or from exhaustion, consequent on the efforts at elimination, 
which in the majority of cases are sooner or later set up, so that, as 
Barnes properly says, " the patient's life may be said to be at the mercy 
of accidents of which we have no sufficient warning." On the other 
hand, if we delay, while we sacrifice all hope of saving the child, we at 
least give the mother the chance of the foetation remaining quiescent for 
a length of time, as certainW not unfrequently occurs. Thus, Campbell 
collected 62 cases of ultimate recovery after abdominal gestation, in 21 
of which the foetus was retained without injury for a number of years. 
Then there is the question of secondary gastrotomy, which consists in 
operating after the death of the foetus when urgent symptoms have 
arisen — a course which is advocated by Mr. Hutchinson. In favor of 
this procedure it is urged that by delay the inflammation taking place 
about the cyst will have greatly increased the chance of adhesions hav- 
ing formed between it and the abdominal parietes, so as to shut off its 
contents from the cavity of the peritoneum. The more effectually this 
has been accomplished, the greater are the chances of recovery. When 
the foetus has been dead for some time, the vascularity of the cyst will 
also be lessened, and the placental circulation will have ceased, so thai 
the danger of hemorrhage will be much diminished. 

It will be seen, therefore, that there are arguments in favor of each 
of these views. The results of the primary operation are far less favor- 
able than we should have, a priori, supposed. Since the firsl edit inn of 
this work appeared the subject has been carefully studied by Dr. Parry 
in his exhaustive treatise on Extra-uterine Foetation. He has there 
shown that when the case is left until nature has shown the channel 
through which elimination is to be effected, the mortality is L7.35 per 
cent, less than in the cases in which the primary operation was performed. 
His conclusion is that " the primary operation cannot be too forcibly con- 



188 PREGNANCY. 

demnecl. It is not too much to say that this operation adds only another 
danger to a life already trembling in the balance, which the delusive 
hope of saving the uncertain life of a child does not warrant us in assum- 
ing." It is only just to remember, as is forcibly pointed out by Keller, 
that in these days of advanced abdominal surgery a better result might 
be anticipated than when gastrotomy was performed in the haphazard 
way which was usual before we had gained experience from ovariotomy. 
No doubt minute care in the performance of the operation, a due atten- 
tion to its details, studiously avoiding as much as possible the passage of 
blood and the contents of the cyst into the peritoneal cavity, and a free 
use of antiseptics, would materially lessen its peril. This conclusion is 
well illustrated in a recent interesting paper by Thomas, who relates 
three successful cases of laparotomy in abdominal pregnancy. 1 

Mode of Performing the Operation. — The operation, then, should be 
performed with all the precautions with which we surround ovariotomy. 
The incision, best made in the linea alba, should not be greater than is 
necessary to extract the foetus, and may be lengthened as occasion requires. 
It has been suggested that should the head be felt presenting above the 
vagina, the intervening structures should be divided and the foetus with- 
drawn by the forceps. This procedure was actually adopted with success 
in 1816 by Dr. John King of Edisto Island, South Carolina. If there 
are no adhesions, the walls of the cyst should be stitched to the margin 
of the incision, so as to shut it off as completely as possible from the 
peritoneal cavity. This has been specially insisted on by Braxton Hicks, 
and should never be omitted. The special risk is not so much the 
wounding of the peritoneum as the subsequent entrance of septic matter 
from the cyst into its cavity. Another cardinal rule, both in primary 
and secondary gastrotomy, is to make no attempt to remove the placenta. 
Its attachments are generally so deep-seated and diffused that any endeav- 
or to separate it is likely to be attended with profuse and uncontrollable 
hemorrhage or with serious injury to the structure to which it is attached. 
Many of the failures after operating can be traced to a neglect of this 
rule. The best subsequent course to pursue, after removing the foetus 
and arresting all hemorrhage either by ligature or the actual cautery, is 
to sponge out the cyst as gently as possible, sprinkle the cavity with 
iodoform or with equal parts of tannin and salicylic acid, as recom- 
mended by Freund, 2 and then to bring the upper part of the wound into 
apposition with sutures, leaving the lower open, with the cord protrud- 
ing, so as to ensure an outlet for the escape of the placenta as it slips 
down. The subsequent treatment must be specially directed to favor 
the escape of the discharge and to prevent the risk of septicaemia. These 
objects may be much aided by injections of antiseptic fluids, such as 
solution of carbolic acid or diluted Condy's fluid ; and it would proba- 
bly be advisable to place a drainage-tube in the lower angle of the 
wound. It may be well to point out that there is no operation in which 
a scrupulous following of the antiseptic method on Sir Joseph Lister's 
principles is so likely to be useful. 

As long as the placenta is retained the danger is necessarily great, and 



1 Am. Journ. of Med. Sei., Jan., 1879. 

2 Edin. Med. Journ,, Dec., 1883. 



ABNORMAL PREGNANCY. 189 

it may be many days, or even weeks, before it is discharged. When 
once this is effected, the sac may be expected to contract, and eventually 
to close entirely. 

[Relative Risks of Primary and Secondary Laparotomy in Abdominal 
Pregnancies. — In view of the improvements in abdominal surgery, 
especially in its application to women, and the disposition that exists to. 
undertake with little hesitation the performance of operations which a 
few years ago were regarded as almost necessarily fatal, it becomes a 
matter of vital importance to consider whether we are justified in 
attempting to save the life of a foetus coming to maturity in the abdom- 
inal cavity by the use of the knife, either by the past record of such 
operations or by any reasonable ground of hope that the inherent diffi- 
culties of the condition may be overcome through the advantages to be 
derived from antiseptics, abdominal drainage, irrigation, etc. 

We are told by some very prominent gynaecologists that the statistics of 
the past are of little value in this operation ; that this is a progressive age 
in abdominal surgery ; and that with the dimunition of risks under Lister- 
ism we ought to be able to do better than in the past, and to overcome the 
dangers and difficulties arising from the vascularity of the cyst wall, the 
activity of the placental circulation, the decomposition and exfoliation 
of the placenta, with its accompanying hemorrhage or septic poisoning, 
and the presence of puriform fluid in the cyst or abdominal cavity. It 
is certainly very tempting to operate in the interest of two lives, and it 
is true that by postponement we run a risk of the patient being lost 
before a time considered safer for operating may arrive. This is a deli- 
cate question to settle, and one Avhich will be appreciated by some of my 
contemporaries who have had this unfortunate experience and regretted 
afterward that they had not operated early. But what is the record of 
the past ? Has not antiseptic surgery had a trial yet ? When asked what 
has been the mortality under the primary operation, fi gynecologist 
will generally refer the applicant to the work of Dr. Parry, already 
referred to, and in it he finds a table of 20 cases of so-called primary 
laparotomies "performed during or at the cud of gestation" and that 6 
of these are stated as having saved the women, with two of their children. 
This record, if reliable, would give a recovery of 80 per cent. — a far 
higher one than will be presently shown from a careful re-examination 
of his statistics. Had Dr. Parry examined the monograph of Dr. Keller 
of Strasbourg, 1 lie would not have fallen into the error I am about to 
point out, as in this paper some of his primary cases arc in the sec- 
ondary list. 

My attention having been directed to some errors in Dr. Parry's sta- 
tistics, I was led to re-examine his sources of information, and am sur- 
prised to find that not one of his six recoveries under primary lapar- 
otomy, so called, was entitled to be thus designated. 

('(isc ~» was operated upon by Dr. Schreyer of Hamburg in is.')?, and 
reported in Casper's Wochenschrift, No. xlw, 1837, page 72<>. 

Case 6, credited to "Schwanck" (correctly Zwanck), is the same as 
Case 5, and was taken from a short abstract report in the Archiv. gen. de 
Med., June, 1838, p. 227, giving the operation to Dr. Zwanck, who was 
[ x Des Gro8se88ee Extra-utirine8, Paris, 1872.] 



190 PREGNANCY. 

the assistant and reporter. The description of the operation shows clearly 
that the fetus was taken out of some form of uterine cavity, from which 
the placenta was readily removed, and that the woman recovered in three 
weeks. Prof. Litzmann of Kiel, Germany, believes that the foetus was 
removed from " a very thin-walled uterus." 

Case 9. Dr. Decouene of Courtrai, France, performed the Cesarean 
operation six times in ten years (1841-51), and saved five women and 
four children. Dr. Parry's reference is incorrect, but these six cases are 
in the volume named. 1 Prof. Litzmann says that the case (9) was a twin 
pregnancy, in which laparotomy was performed after uterine rupture. 

Case 10, Dr. Frederick A. Stutter's. Pregnancy had existed 45 weeks, 
and the foetus, which had been dead five weeks, was already in a putrid 
state. The decomposition hastened the separation of the placenta, which 
Avas removed entire in five days. 

Case 11, Drs. Ramsbotham and Adams's. Here the foetus died just 
before full maturity, and the operation was postponed for safety for six 
months. The woman was then delivered by secondary laparotomy, and 
recovered : she was pregnant for 15 months. 

Case H, Dr. William D. Hooper's of Liberty, Virginia. Dr. Parry 
gives the duration of pregnancy as " 223 days." Having carefully read 
the original record, I am inclined to believe that the foetus was carried 
more than five years. The woman, a two-para, was married a second 
time when in good health. This soon began to fail under some abdomi- 
nal malady, but she menstruated regularly from April 1, 1866, to June, 
1871, with one exception in the latter year, and did not suppose herself 
pregnant. Her health began decidedly to fail in January, 1871, and 
she was a confirmed invalid until operated upon on October 24, 1871. 
She had passed foetal bones from her rectum four months before, and her 
abdomen was about to open spontaneously when she was relieved by the 
knife, and a pmtrid foetus removed without opening the peritoneal cavity. 
The foetus was mainly a skeleton, and was computed as one of at least 
seven months. 

In contrast with Dr. Parry's record, Prof. Litzmann 2 gives one of 10 
genuine primary operations. The children were all living, and were 
delivered alive. The women were pregnant for periods ranging from 29 
weeks to full maturity. Nine of the women died — five on the first day, 
two on the second, one on the third, and one on the sixteenth. Two 
fully-matured children lived and thrived ; a third died in three months, 
and a fourth on the second day. The remaining six lived from a few 
hours to fifty. 

The only surviving woman was the patient of Mr. Jessop of Leeds, 
England, operated upon in 1875. This case, thus far, of all the lapar- 
otomies undertaken in the hope of saving two lives, is the only one 
known to me that has not been a failure so far as the mother was con- 
cerned ; and in this instance the condition of the Avoman for a long time 
gave \ T ery little encouragement of final reco\ T ery, and her child AA r as lost 
at eleven months with croup and pneumonia. A perusal of Mr. Jessop's 

P Gazette, des Hopitaux, Paris, 1852, p. 221.] 

[ 2 Zur Feslstellung der Indicationen fur die Gastrotomie bei Schicangerschaft ausserhalb der 
Gebarmutter, von C. Litzmann, 8vo, pp. 79.] 



ABNORMAL PREGNANCY. 191 

experience with his patient will certainly not encourage one to try a 
similar experiment. 1 

After an extra-uterine fetus is dead within the abdominal cavity, the 
risk of its removal, provided time enough shall have passed for the 
requisite anatomical changes to take place, is very materially diminished, 
as shown by a number of operations in this country and in Europe per- 
formed within a few years. If the woman survives the immediate risk 
of the false labor that usually takes place when the foetus nears maturity, 
she usually improves somewhat in health for a time, by reason* of the 
removal of pressure produced by the absorption of much of the liquor 
amnii. The death of the foetus rendering the placenta no longer of any 
functional importance, this element of danger in the primary operation 
ceases in time to be such, by reason of changes in its structure Avhich fit 
it for undergoing exfoliation without the hemorrhage which follows the 
primary operation. The question, then, of operating becomes one of 
time, which itself has no special limit, as the changes in the placental 
circulation that follow foetal death may be slow or rapid according to 
circumstances ; but experience teaches that from 10 to 12 weeks will be 
sufficient. Much less than this will be required where decomposition has 
commenced ; and in that event an earlier operation may be demanded 
on account of the failing health of the Avoman. Case 10, already noted, 
was an example of this, the foetus having been dead only five weeks. In 
one case in which I was consulted a decomposing foetus was removed 
when four months dead, but for some weeks the patient had been suffer- 
ing from a slow blood-poisoning, with pulse 105, and attacks of mental 
distress and nervous excitement at night : this woman is now in excel- 
lent health. It is not necessary here to defend the secondary operation 
or to collect its statistics in proof of its comparative safety in skilful 
hands, as abundant evidence of this is shown in the reports of cases in 
medical journals. Antiseptic surgery, drainage, and irrigation here avail, 
as the placenta, if left intact, will usually come away without hemor- 
rhage. Dr. Parry condemned the primary operation in strong terms, 
although his statistics gave a measure of hope for its success. Later in 
life he lost a primary case by delay, and regretted not having operated ; 
but he need not have done so, except for the possibility of saving the 
foetus, and it might be then for a few days only. — Ed.] 

Treatment when the Foetus is Dead. — When the foetus is dead, or when 
we have determined not to attempt primary gastrotomy, it is advisable 
to wait, very carefully watching the patient, until either the gravity of 
her general symptoms or some positive indication of the channel through 
which nature is about to attempt to eliminate the fetus shows us that the 
time for action has arrived. If there be distinct bulging of the cyst in 
the vagina or in the retro-vaginal cul-de-sac, especially if an opening has 
formed there, we may properly content ourselves with aiding the passage 
of the fetus through the channel thus indicated, and removing the parts 
that present piecemeal as they come within reach, cautiously enlarging 
the aperture if necessary. If the sac have opened into the intestines, the 
expulsion of the foetus through this channel is so tedious and difficult, 

\} Dr. Werth of Kiel stated before the Int. Med. Congress of 1884 that he had collected 
the records of 17 operations, with two recoveries.] 



192 PREGNANCY. 

the exhaustion attending it so likely to prove fatal, and the danger from 
decomposition of the foetus through passage of intestinal gas so great, 
that it would probably be best to attempt to remove it by gastrotomy, 
especially if it is only recently dead and the greater portion is still 
retained. 

Mode of Performing Secondary Gastrotomy. — If an opening forms at 
the abdominal parietes, or if the symptoms determine us to resort to 
secondary gastrotomy before this occurs, the operation must be per- 
formed in the same way and with the same precautions as primary gas- 
trotomy. Here, as before, the safety of the operation must greatly 
depend on the amount and firmness of the adhesions, for if the cyst be 
not completely shut off from the peritoneal cavity the risks of the opera- 
tion will be little less than those of primary gastrotomy. It would 
obviously materially influence our decision and prognosis if we could 
determine this point before operating. Unfortunately, it is impossible, 
as the experience of ovariotomists proves, to ascertain the existence of 
adhesions with any certainty. If, however, we find that the abdominal 
parietes do not move freely over the cyst, and if the umbilicus be 
depressed and immovable, the presumption is that considerable adhe- 
sions exist. If they are found not to be present, the cyst walls should 
be stitched to the margin of the incision, in the manner already indi- 
cated, before the contents are removed. 

If the foetus has been long dead and its tissues greatly altered, its 
removal may be a matter of difficulty. In the case under my own care, 
already alluded to, the foetal structures formed a sticky mass of such a 
nature that I believe it would have been impossible to empty the cyst 
had an operation been attempted. This would be, to some extent, a 
further argument in favor of the primary operation. 

Opening of Cyst by Caustics. — The importance of adhesions has led 
some practitioners to recommend the opening of the cyst by potassa fusa 
or some other caustic, in the hope that it would set up adhesive inflam- 
mation around the aperture thus formed. Several successful operations 
by this method are recorded, and it would be worth trying should the 
extreme mobility of the cyst lead us to suspect that no adhesions 
existed. If we have to deal with a case in which fistulous openings 
leading to the cyst have already formed, it may, perhaps, be advisable 
to dilate the apertures already existing, rather than make a fresh 
incision ; but in determining this point the surgeon will naturally be 
guided by the nature of the case and the character and direction of the 
fistulous openings. 

General Treatment. — It is almost needless to say anything of general 
treatment in these trying cases, but the administration of opiates to allay 
the sufferings of the patient, and the endeavor to support the severely- 
taxed vital energies by appropriate food and medication, will form a 
most important part of the management. Freund specially insists on 
the importance of careful regulation of the bowels, and on making milk 
the staple article of diet, as important points in the management of cases 
prior to operation. 

Gestation in a. Bilobed Uterus. — A few words may be said as to 
gestation in the rudimentary horn of a bilobed uterus, to which con- 



ABNORMAL PREGNANCY. 193 

siclerable attention has of late years been directed by the writings of 
Kussmaul and others. It appears certain that many cases of supposed 
tubal gestation are really to be referred to this category. Although 
such cases are of interest pathologically, they scarcely require much dis- 
cussion from a practical point of view, inasmuch as their history is 
pretty nearly identical with that of tubal pregnancy. The rudimentary 
horn is distended by the enlarging ovum, and after a time, when further 
distension is impossible, laceration takes place. As a matter of fact, all 
the thirteen cases collected by Kussmaul terminated in this way ; and 
even on post-mortem examination it is often extremely difficult to dis- 
tinguish them from tubal pregnancies. The best way of doing so is 
probably by observing the relations of the round ligaments to the 
tumor, for if the gestation be tubal they will be found attached to the 
uterus on the inner or uterine side of the cyst, whereas if the pregnancy 
be in a rudimentary horn of the uterus they will be pushed outward 
and be external to the sac. In the latter case, moreover, the sac will 
be probably found to contain a true decidua, which is not the case in 
tubal pregnancy. The only point in which they differ is that in cor- 
nual pregnancy rupture may be delayed to a somewhat later period 
than in tubal, on account of the greater distensibility of the supple- 
mentary horn. 

Hissed Labor. — The term "missed labor" is applied to an exceed- 
ingly rare class of cases in which, at the full period of pregnancy, labor 
has either not come on at all, or, having commenced, the pains have 
subsequently passed off, and the foetus is retained in utero for a very 
considerable length of time. Under such circumstances it has usually 
happened that the membranes have ruptured at or about the proper 
term, and the access of air to the foetus in utero has been followed by 
decomposition. A putrid and offensive discharge has then commenced, 
and eventually portions of the disintegrating foetus have been expelled 
per vaginam. This discharge may go on until the entire foetus is grad- 
ually thrown off, or, more frequently, the patient dies from septicaemia 
or other secondary result of the presence of the decomposing mass in 
utero. Thus, McClintock relates one case 1 in which symptoms of labor 
came on in a woman, 45 years of age, at the expected period of delivery, 
but passed off without the expulsion of the foetus. For a period of 
-ixtv-seven weeks a highly offensive discharge came away, with some 
few bones, and she eventually died with symptoms of pyaemia. He also 
cites another case in which the patient died in the same way after the 
foetus had been retained for eleven years. 

Ulceration of the Uterine Walls sometimes Occurs. — Sometimes, when 
the foetus has been retained for a length of time, a further source of 
danger has been added by ulceration or destruction of the uterine wall-, 
probably in consequence of an ineffectual attempt at its elimination. 
This occurred in Dr. Oldham's case (Fig. 86), in which the contained 
mass is said to have nearly worn through the anteriorwall of the uterus; 
and also in one reported by Sir James Simpson, 2 in which a patient died 
three months after term, the fetus having undergone fatty metamor- 
phosis, an opening the size of half a crown having formed between the 

1 Dublin Quart. Journ., Feb. and May, 1864. ■ Edin. Med. Journ., 

13 



194 



PREGNANCY. 



transverse colon and the uterine cavity. It is also stated that "the 
uterine walls were as thin as parchment." 

In some few cases, however, probably when the entrance of air has 
been prevented, the foetus has been retained for a length of time with- 
out decomposing and without giving rise to any troublesome symptoms. 



Fig. 86. 




Contents of the Cyst in Dr. Oldham's Case of Missed Labor. 

Such a case is reported by Dr. Cheston, 1 in which the foetus remained in 
utero for fifty-two years. 

Its Causes are not Properly Understood. — The causes of this strange 
occurrence are altogether unknown. Generally, the foetus seems to have 
died some time before the proper term for labor, and this may have influ- 
enced the character of the pains. It is probably also most apt to occur 
in women of feeble and inert habit of body, possibly where there was 
some obstacle to the dilatation of the cervix which the pains were 
unable to overcome. Barnes suggests 2 that some presumed examples 
of missed labor " were really cases of interstitial gestation, or gestation 
in one horn of a two-horned uterus." In several of the cases, however, 
the details of the post-mortem examination are too minute to admit of the 
possibility of mistake having been made. 

Sometimes Confounded ivith Extra-uterine Foetation. — M tiller of Nancy 
has recently attempted to prove, by a critical examination of published 
cases, that most examples of so-called " missed labor " were in reality 
cases of extra-uterine foetation, in which an ineffectual attempt at par- 
turition took place, the foetus being subsequently retained. 

Its Dangers are Serious. — From what has been said, it will be seen 



1 Med.-Chir. Trans., 1814. 



2 Diseases of Wc 



445. 



ABNORMAL PREGNANCY. 195 

that the dangers arising from this state are very considerable, and when 
once the full term has passed beyond doubt, especially if the presence of 
an offensive discharge shows that decomposition of the foetus has com- 
menced, it would be proper practice to empty the uterus as soon as pos- 
sible. The necessary precaution, however, is not to decide too quickly 
that the term has really passed ; and therefore we must either allow suf- 
ficient time to elapse to make it quite certain that the case really falls 
under this category or have unequivocal signs of the death of the foetus 
and injury to the mother's health. If we had to deal with the case 
before any extensive decomposition of the foetus had occurred, we proba- 
bly should find little difficulty in its management, for the proper course 
then would be to dilate the cervix with fluid dilators and remove the 
foetus by turning; or, before doing so, we might endeavor to excite 
uterine action by pressure and ergot. If the case did not come under 
observation until disintegration of the foetus had begun, it would be 
more difficult to deal with. If the foetus had become so much broken 
up that it was being discharged in pieces, Dr. McClintock says that " in 
regard to treatment our measures should consist mainly of palliatives — 
viz. rest and hip-baths, to subdue uterine irritation ; vaginal injections, 
to secure cleanliness and prevent excoriation ; occasional digital exam- 
ination, so as to detect any fragments of bone that might be presenting 
at the os and to assist in removing them. These are plain rational 
measures, and beyond them we shall scarcely, perhaps, be justified in 
venturing. Nevertheless, under certain circumstances, I would not 
hesitate to dilate the cervical canal so as to permit of examining the 
interior of the womb and of extracting any fragments of bone that may 
be easily accessible ; but unless they could thus be easily reached and 
removed, the safer course would be to defer, for the present, interfering 
with them." l 

It may be doubted, I think, whether, considering the serious results 
which are known to have followed so many cases, it would not, on the 
whole, be safer to make at least one decided effort, under chloroform, to 
remove as much as possible of the putrefying uterine contents after the 
OS lias been fully dilated. Such a procedure would be less irritating 
than frequently-repeated endeavors to pick away detached portions of 
the fetus as they present at the os uteri. When once the os is dilated, 
antiseptic intra-uterine injections, as of diluted Condy's fluid, might 
safely and advantageously be used. Unquestionably, it would be better 
practice to interfere and empty the uterus as soon as we are quite satis- 
fied of the nature of the case, rather than to delay until the fetus has 
been disintegrated. 

[From several cases of " missed labor" that have been reported in the 
United States we find that the failure of the uterus to expel its contents 
may be due to a variety of causes. If we arc certain that the foetus is 
actually in utero, that there is no pelvic or vaginal obstruction, and that 
the uterus is itself of normal form, then we must look for the <;m-<' of 
difficulty in the organ itself. By an examination of our reports of 
Csesarean operations we find that there have been several eases ill which 
the power of the uterine contractions was insufficienl to overcome the 

1 Dublin Quart. Joum., vol. xxxvii. p. 3] 1. 



196 PREGNANCY. 

resistance to expansion in the cervix. This may be due either to a want 
of contractile force in the muscular coat, to a change in the tissues of the 
cervix as the result of inflammation, or to both conditions combined. 
Where the muscular power of the uterus is in its integrity, the resistance 
in the cervix may be such that the os may remain unchanged after it is 
slightly opened, and the patient continue in labor until the contractile 
power of the uterus is exhausted, when all muscular contraction will 
cease. Efforts at expulsion may recur at intervals covering a period of 
many months, when they will cease finally. In two Cesarean cases in 
the United States, the subjects being black, there was found a calcareous 
incrustation over and around the internal os uteri. The first operation 
was performed in Virginia in 1828 upon a multipara of 25. 1 She was 
taken in labor at term, and had pains for two or three days together, at 
intervals, for about four weeks, after which pains returned occasionally 
during fifteen months. The cervix admitted the index finger, and in 
time the foetus became putrid. When operated upon she had carried 
the foetus two years. There was very little hemorrhage in the opera- 
tion, although the uterus failed to contract, and for this reason was 
sutured. The woman died in the second week, of peritonitis, following 
an attack of indigestion produced by a meal of animal food and cider. 
The second case, also a multipara, was operated upon in Georgia in 
1877, after a labor of four days, by Dr. Theodore Starbuck, who 
describes the deposit as " ossific." The child was dead, and the woman 
died of internal hemorrhage very suddenly on the third day. 2 

In a third case, also black, the cause of retention appears to have been 
a prevention of the descent of the foetus, from its arm and leg being 
secured within the uterus. The woman was 33 years old and the 
mother of one child, and was operated upon by Dr. J. C. Egan of 
Shreveport, Louisiana, August 25, I860. 3 On May 4, 1857, while at 
work in the field, she felt a sudden and violent pain in the left side ; 
fainted, remained insensible so long as to be thought dead, but finally 
revived, and was pronounced four months pregnant. Labor began in 
November ; the os dilated, head presented, but did not descend ; pains 
continued at intervals for a month. In the fall of 1858 an abscess 
opened, leaving a fistula 1^ inches below the umbilicus. When operated 
upon nearly two years later, she was greatly emaciated and affected with 
hectic fever. The uterus being adherent, the peritoneal cavity was not 
opened. When the foetus was extracted, its left foot and hand were 
wanting, and, search being made, were found in a pouch on the left side 
of the uterus, enclosed by bands which were cut for their liberation. 
The uterus was examined bi-manually to make sure that the cervix was 
sufficiently open for drainage. The decomposed foetus had been carried 
33 months after maturity. Dr. Egan believes that a partial rupture of 
the uterus took place at the time of her attack in the field, and that the 
arm and leg were caught in its partial cicatrization. The woman made 
a good recovery. 

1 Am. Journ. Med. Set'., vol. xviii. p. 257.] 

~ 2 Communicated by the operator, 1880.] 

" 3 N. 0. Med. and Surg. Journ., Julv, 1877, p. 35 ; also communicated bv operator, 

1878.] 



ABNORMAL PBEGXAXCY. 197 

Much light is thrown upon a possible way of accounting for some of 
the mysterious cases of missed labor, which have been claimed to be 
extra-uterine in order to account for them, by a case recently operated 
upon in Portland, Maine, by Dr. Stanley P. Warren, and kindly 
reported to me by letter. The woman was a native, of Scotch-Irish 
descent, aged 32, and mother of a child of 13. She last menstruated in 
January, 1884. Supposed accidental abortion in May, as there was 
hemorrhage ; the physician said he had removed the placenta, and there 
was a thick " molasses-like " discharge afterward. Dr. Warren was 
called in a week later ; found metro-peritonitis and a tumor of about 
four inches in diameter in the right groin. The peritonitis became gen- 
eral, and Dr. W. was in attendance for 15 days. On July 1st the 
tumor was in the median line, and foetal movements and heart-sounds 
distinct. Labor expected about October 28th ; subsequent gestation 
normal. Was called October 28th, at 11 P. M. ; found no true pains ; 
pain apparently abdominal, rather than uterine, and continuous in the 
back and over the sides of the uterus. Foetus transverse, with head to 
right ; pulse 152. Xo change for several days. Second week in 
November found child dead. Xext four weeks slight occasional chills, 
and temperature 102° for two or three nights, but usually normal. 
Absolutely no expulsive pains. Cervix reached with difficulty, and fin- 
ger passed through a long tubular neck, but foetus not reached. Cervix 
absolutely closed from December 21st to 29th ; pulse 120, temperature 
100° to 102°. Attempted to dilate with sponge tent, but could not pass 
it into the uterine cavity. December 30th attempted to open cervix by 
digital dilatation, and succeeded finally in passing a cranioclast, but the 
parts closed as soon as the dilators were removed. Patient in a pro- 
found shock. After stimulating for an hour performed Cesarean sec- 
tion ; hemorrhage slight ; peritoneum adherent everywhere to uterus ; 
uterine wall \ inch thick ; child presented by right arm and side ; pla- 
centa thin and far advanced in fatty degeneration ; no hemorrhage on its 
removal ; uterus did not contract ; sutured by continuous stitch with cat- 
gut. Child 8-i- lbs. Woman rallied slightly, but died of shock in 28 
hours. Drs. T. A. Foster and S. C. Gordon were associated with Dr. 
Warren in the management of the case. 

It would appear in this instance of missed labor that the changes pro- 
duced by metro-peritonitis prevented the natural dilatation of the cervix 
and the contractile action of the muscular coat of the uterus. Possibly, 
fatty degeneration of the muscular fibres had taken place, but this could 
not be ascertained, as there was no autopsy. 

The Ceesarean case of Dr. Brodie S. Herndon of Fredericksburg, Vir- 
ginia, operated upon with success in 1845, bears a close resemblance in 
many of its features to that of Dr. Warren. The subject was a white 
multipara of 30, whose pains of labor gave place to the continuous pain 
and other characteristic symptoms of peritonitis. This disease lasted a 
month, during which time the fluid content- of the uterus escaped, and 
the vagina] discharge became very offensive. Five weeks after the peri- 
tonitis commenced the OS uteri admitted two Angers, and attempt- at 
dilatation were made, but failed. Under ergol an offensive placenta was 
expelled, but the foetus could ool be removed. The woman being 



198 PREGNANCY. 

greatly wasted and her room filled with stench, the Cesarean operation 
was performed on November 16th, 46 days after the first signs of labor 
appeared. The uterus being adherent, the peritoneal cavity was not 
exposed ; the uterus was sponged out, but did not contract ; it was 
closed in the suturing of the abdomen. The patient made a good recov- 
ery. As in the Warren case, the uterus became unsuited for performing 
the functions of labor by reason of changes in its tissues effected by 
inflammatory action. — Ed.] 



CHAPTER VII. 

DISEASES OF PREGNANCY. 



Diseases of Pregnancy. — The diseases of pregnancy form a subject so 
extensive that they might well of themselves furnish ample material for 
a separate treatise. The pregnant woman is of course liable to the same 
diseases as the non-pregnant, but it is only necessary to allude to those 
whose course and effects are essentially modified by the existence of 
pregnancy, or which have some peculiar effect on the patient in conse- 
quence of her condition. There are, moreover, many disorders which can 
be distinctly traced to the existence of pregnancy. Some of them are the 
direct results of the sympathetic irritations which are then so common- 
ly observed ; and of these several are only exaggerations of irritations 
which may be said to be normal accompaniments of gestation. These 
functional derangements may be classed under the head of neuroses, and 
they are sometimes so slight as merely to cause temporary inconvenience, 
at others so grave as seriously to imperil the life of the patient. Another 
class of disorders is to be traced to local causes in connection with the 
gravid uterus, and are either the mechanical results of pressure or of 
some displacement or morbid state of the uterus ; while the origin of 
others may be said to be complex, being partly due to sympathetic irri- 
tation, partly to pressure, and partly to obscure nutritive changes pro- 
duced by the pregnant state. 

Derangements of the Digestive System. — Among the sympathetic 
derangements there are none which are more common, and none which 
more frequently produce distress and even danger, than those which 
affect the digestive system. Under the heading of " The Signs of Preg- 
nancy " the frequent occurrence of nausea and vomiting has already 
been discussed, and its most probable causes considered (p. 145). A 
certain amount of nausea is, indeed, so common an accompaniment of 
pregnancy that its consideration as one of the normal symptoms of that 
state is fully justified. We need here only' discuss those cases in which 
the nausea is excessive and long continued, and leads to serious results 
from inanition and from the constant distress it occasions. Fortunately, 
a pregnant woman may bear a surprising amount of nausea and sick- 



DISEASES OF PREGNANCY. 199 

ness without constitutional injury, so that apparently almost all aliments 
may be rejected without the nutrition of the body very materially suf- 
fering. At times the vomiting is limited to the early part of the day, 
when all food is rejected, and when there is a frequent retching of glairy 
transparent fluid, in several cases mixed with bile, while at the Jatter 
part of the day the stomach may be able to retain a sufficient quantity 
of food and the nausea disappears. In other cases the nausea and vom- 
iting are almost incessant. The patient feels constantly sick, and the 
mere taste or sight of food may bring on excessive and painful vomit- 
ing. The duration of this distressing accompaniment of pregnancy is 
also variable. Generally it commences between the second and third 
months, and disappears after the woman has quickened. Sometimes, 
however, it begins with conception, and continues unabated until the 
pregnancy is over. 

Symptoms of the Graver Cases. — In the worst class of cases, when all 
nourishment is rejected and when the retching is continuous and painful, 
symptoms of very great gravity, which may even prove fatal, develop 
themselves. The countenance becomes haggard from suffering, the 
tongue dry and coated, the epigastrium tender on pressure, and a state 
of extreme nervous irritability, attended with restlessness and loss of 
sleep, becomes established. In a still more aggravated degree there is 
general feverishness, with a rapid, small, and thready pulse. Extreme 
emaciation supervenes, the result of wasting from lack of nourishment. 
The breath is" intensely fetid and the tongue dry and black. The vom- 
ited matters are sometimes mixed with blood. The patient becomes pro- 
foundly exhausted, a low form of delirium ensues, and death may follow 
if relief is not obtained. 

Prognosis. — Symptoms of such gravity are fortunately of extreme 
rarity, but they do from time to time arise, and cause much anxiety. 
Gueniot collected 118 cases of this form of the disease, out of which 46 
died ; and out of the 72 that recovered, in 42 the symptoms only ceased 
when abortion, either spontaneous or artificially produced, had occurred. 
When pregnancy is over the symptoms occasionally cease with marvel- 
lous rapidity. The power of retaining and assimilating food is rapidly 
regained, and all the threatening symptoms disappear. 

Treatment. — In the milder forms of obstinate vomiting one of the 
first indications will be to remedy any morbid state of the primse vise. 
The bowels will not (infrequently be found to be obstinately constipated, 
the tongue loaded, and the breatli offensive ; and when attention has been 
paid to the general state of the digestive organs by general aperient 
medicines and antacid remedies, such as bismuth and soda and liquor 
pepticus after meals, the tendency to vomiting may abate without fur- 
ther treatment. 

Regulation of Diet. — The careful regulation of the diet is very import- 
ant. Great benefit is often derived from recommending the patient not 
to rise from the recumbent position in the morning until she has taken 
something. Half a cup of milk and lime-water, or a cup of strong 
coffee, or a little rum and milk, or cocoa and milk, a glass of sparkling 
koumiss, or even a morsel of biscuit, taken on waking, often has a 
remarkable effect in diminishing the nausea. When any attempt at. 



200 PREGNANCY. 

swallowing solid food brings on vomiting, it is better to give up all pre- 
tence at keeping to regular meals, and to order such light and easily- 
assimilated food, at short intervals, as can be retained. Iced milk, with 
lime- or soda-water, given frequently and not more than a mouthful at 
a time, will frequently be retained when nothing else will. Cold beef- 
jelly, a spoonful at a time, will also be often kept down. Sparkling 
koumiss has been strongly recommended as very useful in such cases, 
and is worthy of trial. It is well, however, to bear in mind, in regulat- 
ing the diet, that the stomach is fanciful and capricious, and that the 
patient may be able to retain strange and apparently unlikely articles 
of food, and that, if she express a desire for such, the experiment of 
letting her have them should certainly be tried. 

Medicinal Treatment — The medicines that have been recommended 
are innumerable, and the practitioner will often have to try one after the 
other unsuccessfully, or may find, in an individual case, that a remedy 
will prove valuable which in another may be altogether powerless. 
Amongst those most generally useful are effervescing draughts contain- 
ing from three to five minims of dilute hydrocyanic acid ; the creasote 
mixture of the Pharmacopoeia ; tincture of nux vomica, in doses of five 
or ten minims ; single minim-doses of vinum ipecacuanha?, every hour 
in severe cases, three or four times daily in those which are less urgent ; 
salicin, in doses of three to five grains three times a day, recommended 
by Tyler Smith ; oxalate of cerium in the form of pill, of which three 
to five grains may be given three times a day — a remedy strongly advo- 
cated by Sir James Simpson, and which occasionally is of undoubted 
service, but more often fails ; the compound pyroxylic spirit of the Lon- 
don Pharmacopoeia, in doses of five minims every four hours, with a 
little compound tincture of cardamom — a drug which is comparatively 
little known, but which occasionally has a very marked and beneficial 
effect in checking vomiting ; opiates in various forms — which sometimes 
prove useful, more often not — may be administered either by the mouth, 
in pills containing from half a grain to a grain of opium, or in small 
doses of the solution of the bimeconate of morphia or of Battley's seda- 
tive solution, or subcutaneously — a mode of administration which is 
much more often successful. If there is much tenderness about the epi- 
gastrium, one or two leeches may be advantageously applied, or one- 
third of a grain of morphia may be sprinkled on the surface of a small 
blister, or cloths saturated in laudanum may be kept over the pit of the 
stomach. The administration per rectum of twenty grains of chloral, 
combined with the same amount of bromide of potassium, in a small 
enema, is said to be very useful. In many cases I have found that the 
application of a spinal ice-bag to the cervical vertebrae, in the manner 
recommended by Dr. Chapman, has checked the vomiting when all 
drugs have failed. The ice may be placed in one of Chapman's spinal 
ice-bags, and applied for half an hour or an hour twice or three times a 
day. It invariably produces a comforting sensation of warmth, which 
is always agreeable to the patient. Ice may be given to suck ad libitum, 
and is very useful ; while, if there be much exhaustion, small quantities 
of iced champagne may also be given from time to time. 

Local Treatment. — Inasmuch as the vomiting unquestionably has its 



DISEASES OF PREGNANCY. 201 

origin in the uterus, it is only natural that practitioners should endeavor 
to cheek it by remedies calculated to relieve the irritability of that organ. 
Thus, morphia in the form of pessaries per vaginain, or belladonna 
applied to the cervix, has been recommended ; the former especially are 
often of undoubted service. A pessary containing one-third to half a 
grain of morphia may be introduced night and morning without inter- 
fering with other methods of treatment. Dr. Henry Bennet directs 
especial attention to the cervix, which, he says, is almost always con- 
gested and inflamed and covered with granular erosions. This condition 
he recommends to be treated by the application of nitrate of silver 
through the speculum. Dr. Clay of Manchester corroborates this view, 
and strongly advocates, especially when vomiting continues in the latter 
months, that one or two leeches should be applied to the cervix. Excep- 
tion may fairly be taken to both these methods of treatment as being 
somewhat hazardous, unless other means have been tried and failed. I 
have little doubt, however, that in many cases a state of uterine conges- 
tion is an important factor in keeping up the unduly irritable condition 
of the uterine fibres, and an endeavor should always be made to lessen 
it by insisting on absolute rest in the recumbent posture. Of the import- 
ance of this precaution in obstinate cases there can be no question. Dr. 
Chapman of Xorwich strongly recommended dilatation of the cervix by 
the finger, and stated that he found it very serviceable in checking nausea. 
It is obvious that this treatment must be adopted with great caution, as, 
roughly performed, it might lead to the production of abortion. Dr. 
Hewitt's views as to the dejDendence of sickness on flexions of the uterus 
have alreadvbeen adverted to, and reasons have been given for doubting 
the general correctness of his theory. It is quite likely, however, that 
well-marked displacements of the uterus, either forward or backward, 
may serve to intensify the irritability of the organ. Cazeaux mention- an 
obstinate case immediately cured by replacing a retro verted uterus. A 
careful vaginal examination should therefore be instituted in all intract- 
able cases, and if distinct displacement be detected an endeavor should be 
made to support the uterus in its normal axis. If retro verted, a Hodge's 
pessary may be safely employed; if anteverted, a small air-ball pessary, 
as recommended by Hewitt, should be inserted. I believe, however. 
that such displacements are the exception, rather than the rule, in cases 
of severe sickness. 

Importance of Promoting the Nutrition of the Patient. — The import- 
ance of promoting nutrition by every means in our power should always 
be borne in mind. The effervescing koumiss, which can now be readily 
obtained, I have found of great value, as it can often !>•' retained when 
all other aliment is rejected. The exhaustion produced by want of fond 
soon increases the irritable state of the nervous system, and if the stom- 
ach will not retain anything, we can only combat it by occasional nutri- 
ent enemata of strong beef-tea, yelk of egg, and the like. 

The Production of A,-flfi<->n/ Abortion. — Finally, in the worsl class 
of cases when all treatment has nailed and when the patient ha- fallen 
into the condition of extreme prostration already described, we may be 
driven to consider the necessity of producing abortion. Fortunately, 
cases justifying this extreme resource are of great rarity, bul Qeverthelese 



202 PREGNANCY. 

there is abundant evidence that every now and then women do die from 
uncontrollable vomiting whose lives might have been saved had the 
pregnancy been brought to an end. The value of artificial abortion has 
been abundantly proved. Indeed, it is remarkable how rapidly the 
serious symptoms disappear when the uterus is emptied and the tension 
of the uterine fibres lessened. It has fortunately but rarely fallen to my 
lot to have to perform this operation for intractable vomiting. In one 
such case the patient was reduced to a state of the utmost prostration, 
having kept hardly any food on her stomach for many weeks, and when 
I first saAV her she was lying in a state of low muttering delirium. 
Within a few hours after abortion was induced all the threatening symp- 
toms had disappeared, the vomiting had entirely ceased, and she was 
next day able to retain and absorb all that was given to her. The value 
of the operation, therefore, I believe to be undoubted. Where it has 
failed it seems to have been on account of undue delay. Owing to the 
natural repugnance which all must feel toward this plan, it has gener- 
ally been postponed until the patient has been too exhausted to rally. 
If, therefore, it is done at all, it should be before prostration has 
advanced so far as to render the operation useless. In these cases the 
obvious indication is to lessen the tension of the uterus at once, and 
therefore the membranes should be punctured by the uterine sound, so as 
to let the liquor amnii drain away ; and this may of itself be sufficient 
to accomplish the desired effect. It is almost needless to add that no 
one would be justified in resorting to this expedient without having his 
opinion fortified by consultation with a fellow-practitioner. 

Other Disorders of the Digestive System. — Other disorders of the 
digestive system may give rise to considerable discomfort, but not to the 
serious peril attending obstinate vomiting. Amongst them are a loss of 
appetite, acidity and heartburn, flatulent distension, and sometimes a 
capricious appetite, which assumes the form of longing for strange and 
even disgusting articles of diet. Associated with these conditions there 
is generally derangement of the whole intestinal tract, indicated by 
furred tongue and sluggish bowels, and they are best treated by remedies 
calculated to restore a healthy condition of the digestive organs, such as 
a light, easily-digested diet, mineral acids, vegetable bitters, occasional 
aperients, bismuth and soda, and pepsin. The indications for treatment 
are not different from those which accompany the same symptoms in the 
non-pregnant state. 

Diarrhoea. — Diarrhoea is an occasional accompaniment of pregnancy, 
often depending on errors of diet. When excessive and continuous it 
has a decided tendency to induce uterine contractions, and I have 
frequently observed premature labor to follow a sharp attack of diar- 
rhoea. It should, therefore, not be neglected, and if at all excessive 
should be checked by the usual means, such as chalk mixture with aro- 
matic confection and small doses of laudanum or chlorodyne. The 
possibility of apparent diarrhoea being associated with actual constipa- 
tion, the fluid matter finding its way past the solid materials blocking up 
the intestines, should be borne in mind. 

Constipation. — Constipation is much more common, and is indeed a 
very general accompaniment of pregnancy, even in women who do not 



DISEASES OF PREGNANCY. 203 

suffer from it at other times. It partly depends on the mechanical inter- 
ference of the gravid uterus with the proper movements of the intestines, 
and partly on defective innervation of the bowels resulting from the 
altered state of the blood. The first indication will be to remedy this 
defect by appropriate diet, such as fresh fruits, brown bread, oatmeal 
porridge, etc. Some medicinal treatment will also be necessary, and in 
selecting the drugs to be used care should be taken to choose such as are 
mild and unirritating in their action and tend to improve the tone of the 
muscular coat of the intestine. A small quantity of aperient mineral 
water in the early morning, such as the Hunyadi, Friedrichshall, or 
Pullna water, often answers very well ; or an occasional dose of the con- 
fection of sulphur ; or a pill containing three or four grains of the 
extract of colocynth, with a quarter of a grain of the extract of nux 
vomica and a grain of extract of hyoscyamus at bedtime ; or a teaspoon- 
ful of the compound liquorice powder in milk at bedtime. Constipation 
is also sometimes effectually combated by administering, twice daily, a 
pill containing a couple of grains of the inspissated ox-gall with a quar- 
ter of a grain of extract of belladonna. Enemata of soap and water 
are often very useful, and have the advantage of not disturbing the 
digestion. In the latter months of pregnancy, especially in the few 
weeks preceding delivery, the irritation produced by the collection of 
hardened feces in the bowel is a not infrequent cause of the annoying 
false pains which then so commonly trouble the patient. In order to 
relieve them it will be necessary to empty the bowels thoroughly by an 
aperient, such as a good dose of castor oil, to which fifteen or twenty 
minims of laudanum may be advantageously added. Should the rectum 
become loaded with scybalous masses, it may be necessary to break down 
and remove them by mechanical means, provided we are unable to effect 
this by copious enemata. 

Hemorrhoids. — The loaded state of the rectum so common in preg- 
nancy, combined with the mechanical effect of the pressure of the gravid 
uterus on the hemorrhoidal veins, often produces very troublesome symp- 
toms from piles. In such cases a regular and gentle evacuation of the 
bowels should be secured daily, so as to lessen as much as possible the 
congestion of the veins. Any of the aperients already mentioned, espe- 
cially the sulphur electuary, may be used. Dr. Fordyce Barker 1 insi-ts 
that, contrary to the usual impression, one of the best remedies for this 
purpose is a pill containing a grain or a grain and a half of powdered 
aloes, with a quarter of a grain of extract of nux vomica, and that cas- 
tor oil is distinctly prejudicial and apt to increase the symptoms. I 
have certainly found it answer well in several cases. When the piles are 
tender and swollen, they should be freely covered with an ointment con- 
sisting of four grains of muriate of morphia to an ounce of simple oint- 
ment, or with the ung. gallse c. opio of the Pharmacopoeia ; and, if pro- 
truded, an attempt should be made to push them gently above the 
sphincter, by which they are often unduly constricted. Relief may also 
be obtained by frequent hot fomentations, and sometimes, when the piles 
are much swollen, it will be found useful to puncture them, so a- to 
lessen the congestion before any attempt at reduction is made. 
1 The Puerperal Diseases, p. 33. 



204 PREGNANCY. 

Ptyalism. — A profuse discharge from the salivary glands is an occa- 
sional distressing accompaniment of pregnancy. It is generally confined 
to the early months, but it occasionally continues during the whole 
period of gestation, and resists all treatment, only ceasing when delivery 
is over. Under such circumstances the discharge of saliva is sometimes 
enormous, amounting to several quarts a day, and the distress and 
annoyance to the patient are very great. In one case under my care 
the saliva poured from the mouth all day long, and for several months 
the patient sat with a basin constantly by her side, incessantly emptying 
her mouth, until she was reduced to a condition giving rise to really 
serious anxiety. This profuse salivation is no doubt a purely nervous 
disorder, and not readily controlled by remedies. Astringent gargles, 
containing tannin and chlorate of potass, frequent sucking of ice or of 
tannin lozenges, inhalation of turpentine and creasote, counter-irritation 
over the salivary glands by blisters or iodine, the bromides, opium 
internally, small doses of belladonna or atropine, may all be tried in 
turn, but none of them can be depended on with any degree of confi- 
dence. 

Toothache and Caries of the Teeth. — Severe dental neuralgia is also a 
frequent accompaniment of pregnancy, especially in the early months. 
When purely neuralgic, quinine in tolerably large doses is the best 
remedy at our disposal ; but not unfrequently it depends on actual 
caries of the teeth, and attention should always 'be paid to the condition 
of the teeth when facial neuralgia exists. There is no doubt that preg- 
nancy predisposes to caries, and the observation of this fact has given 
rise to the old proverb, " For every child a tooth." Mr. Oakley Coles, 
in an interesting paper 1 on the condition of the mouth and teeth during 
pregnancy, refers the prevalence of caries to the coexistence of acid 
dyspepsia, causing acidity of the oral secretions. There is much unrea- 
sonable dread amongst practitioners as to interfering with the teeth 
during pregnancy, and some recommend that all operations, even stop- 
ping, should be postponed until after delivery. It seems to me certain 
that the suffering of severe toothache is likely to give rise to far more 
severe irritation than the operation required for its relief, and I have 
frequently seen badly-decayed teeth extracted during pregnancy, and 
with only a beneficial result. 

Affections of the Respiratory Organs. — Amongst the derangements of 
the respiratory organs, one of the most common is spasmodic cough, 
which is often excessively troublesome. Like many other of the sym- 
pathetic derangements accompanying gestation, it is purely nervous in 
character, and is unaccompanied by elevated temperature, quickened 
pulse, or any distinct auscultatory phenomena. In character it is not 
unlike whooping cough. The treatment must obviously be guided by 
the character of the cough. Expectorants are not likely to be of ser- 
vice, while benefit may be derived from some of the antispasmodic class 
of drugs, such as belladonna, hydrocyanic acid, opiates, or bromide of 
potassium. Such remedies ltiay be tried in succession, but will often be 
found to be of little value in arresting the cough. Dyspnoea may also 
be nervous in character, and sometimes symptoms not unlike those of 

1 Trans, of the Odontological Society. 



DISEASES OF PREGNANCY. 205 

spasmodic asthma are produced. Like the other sympathetic disorders, 
it, as well as nervous cough, is most frequently observed during the 
early months. There is another form of dyspnoea, not uncommonly 
met with, which is the mechanical result of the interference with the 
action of the diaphragm and lungs by the pressure of the enlarged 
uterus. Hence this is most generally troublesome in the latter months, 
and continues unrelieved until delivery or until the sinking of the ute- 
rine tumor which immediately precedes it. Beyond taking care that the 
pressure is not increased by tight-lacing or injudicious arrangement of 
the clothes, there is little that can be done to relieve this form of breath- 
lessness. 

[In some instances the difficulty of respiration is particularly distress- 
ing when the patient attempts to lie down in bed, and sleep is rendered 
broken and unrefreshing. In such cases two points are indicated : we 
must elevate the chest, and at the same time relieve the tension of the 
abdomen. This is best accomplished by the use of an inclined plane, in 
the form of a wide board padded with pillows, resting on the head and 
middle of the bed at its two ends. The patient is to rest her back upon 
this in a half-reclining position, and have her knees elevated with a 
pillow under them, on which she virtually, as it were, sits. This I 
have found to give great relief, especially to primiparse, who are apt to 
suifer from diaphragmatic pressure and abdominal resistance. Inunc- 
tion of the abdomen will also be found of value. — Ed.] 

Palpitation. — Palpitation, like dyspnoea, may be due either to sympa- 
thetic disturbance or to mechanical interference with the proper action 
of the heart. When occurring in weakly women, it may be referred to 
the functional derangements which accompany the chlorotic condition 
of the blood often associated with pregnancy, ' and is then best remedied 
by a general tonic regimen and the administration of ferruginous prep- 
arations. At other times antispasmodic remedies may be indicated, and 
it is seldom sufficiently serious to call for much special treatment. 

Syncope. — Attacks of fainting are not rare, especially in delicate 
women of highly-developed nervous temperament, and are, perhaps, 
most common at or about the period of quickening. Tn most cases 
these attacks cannot be classed as cardiac, but are more probably nerv- 
ous in character, and they are rarely associated with complete abolition 
of consciousness. They rather, therefore, resemble the condition de- 
scribed by the older authors as lypothcemia. 'Fhe patient lies in a semi- 
unconscious condition with a feeble pulse and widely-dilated pupils, and 
this state lasts for varying periods, from a few minutes to half an hour 
or more. In one very troublesome case under my en re they often re- 
curred as frequently as three or four times a day. I have observed that 
they rarely occur when the more common sympathetic phenomena ofpreg^- 
nancy, especially vomiting, are present. Sometimes they terminate with 
the ordinary symptoms of hysteria, such as sobbing. Tin* treatmenl 
should consist during the attack in the administration of diffusible 
stimulants, such as ether, sal-volatile, and valerian, the patient being 
placed in the recumbent position, with the head low. If frequently 
repeated it is unadvisable to attempt to rally the patient by the t<»<> free 
administration of stimulants. In the intervals a generally tonic regimen 



206 PREGNANCY. 

and the administration of ferruginous remedies are indicated. If they 
recur with great frequency the daily application of the spinal ice-bag 
has proved of much service. 

Extreme Ancemia and Chlorosis. — In connection with disorders of the 
circulatory system may be noticed those which depend on the state of 
the blood. The altered condition of the blood, which has already been 
described as a physiological accompaniment of pregnancy (p. 139), is 
sometimes carried to an extent which may fairly be called morbid; and 
either on account of the deficiency of blood-corpuscles or from the 
increase in its watery constituents a state of extreme anaemia and chlo- 
rosis may be developed. This may be sometimes carried to a very 
serious extent. Thus, Gusserow 1 records five cases in which nothing 
but excessive anaemia could be detected, all of which ended fatally. 
Generally, when such symptoms have been carried to an extreme ex- 
tent, the patient has been in a state of chlorosis before pregnancy. The 
treatment must, of course, be calculated to improve the general nutri- 
tion and enrich the impoverished blood ; a light and easily-assimilated 
diet, milk, eggs, beef-tea, and animal food — if it can be taken — atten- 
tion to the proper action of the bowels, a due amount of stimulants, and 
abundance of fresh air, will be the chief indications in the general man- 
agement of the case. Medicinally, ferruginous preparations will be 
required. Some practitioners object, apparently without sufficient rea- 
son, to the administration of iron during pregnancy as liable to promote 
abortion. This unfounded prejudice may probably be traced to the 
supposed emmenagogue properties of the preparations of iron ; but if 
the general condition of the patient indicate such medication they may 
be administered without any fear. Preparations of phosphorus, such as 
the phosphide of zinc, or free phosphorus, also promise favorably, and 
are worthy of trial. 

(Edema associated with Hydremia. — Some of the more aggravated 
cases are associated with a considerable amount of serous effusion into 
the cellular tissue, generally limited to the lower extremities, but occa- 
sionally extending to the arms, face, and neck, and even producing 
ascites and pleuritic effusion. Under the latter circumstances this com- 
plication is, of course, of great gravity, and it is said that after delivery 
the disappearance of the serous effusion may be accompanied by meta- 
stasis of a fatal character to the lungs or the nervous centres. This form 
of oedema must be distinguished from the slight ©edematous swelling of 
the feet and legs so commonly observed as a mechanical result of the 
pressure of the gravid uterus, and also from those cases of oedema asso- 
ciated with albuminuria. The treatment must be directed to the cause, 
while the disappearance of the effusion may be promoted by the admin- 
istration of diuretic drinks, the occasional use of saline aperients, and 
rest in the horizontal position. 

Albuminuria. — The existence of albumen in the urine of pregnant 
women has for many years attracted the attention of obstetricians, and it 
is now well known to be associated, in ways still imperfectly understood, 
with many important puerperal diseases. Its presence in most cases of 
puerperal eclampsia was long ago pointed out by Lever in this country 

1 Arch.f. Gyn., ii. 2, 1871. 



DISEASES OF PREGNANCY. 207 

and Raver in France, and its association with this disease gave rise to the 
theory of the dependence of the convulsion on uraemia which is generally 
still entertained. It has been shown of late years, especially by Braxton 
Hicks, that this association is by no means so universal as was supposed ; 
or, rather, that in some cases the albuminuria follows and does not pre- 
cede the convulsions, of which it might therefore be supposed to be the 
consequence rather than the cause ; so that further investigations as to 
these particular points are still required. Modern researches have shown 
that there is an intimate connection between many other affections and 
albuminuria ; as, for example, certain forms of paralysis, either of special 
nerves, as puerperal amaurosis, or of the spinal system ; cephalalgia 
and dizziness ; puerperal mania ; and possibly hemorrhage. It cannot, 
therefore, be doubted that albuminuria in the pregnant woman is liable, 
at any rate, to be associated with grave disease, although the present 
state of our knowledge does not enable us to define very distinctly its 
precise mode of action. 

Causes of Puerperal Albuminuria. — The presence of albumen in the 
urine of pregnant women is far from a rare phenomenon. Blot and 
Litzman met with albuminuria in 20 per cent, of pregnant women, which 
is, however, far above the estimate of other authors ; Fordyce Barker l 
thinks it occurs in about 1 out of 25 cases, or 4 per cent.; while Hofmier 2 
found it in 137 out of 5000 deliveries in the Berlin Gynaecological 
Institution, or 2.74 per cent. As in the large majority of these cases it 
rapidly disappears after delivery, it is obvious that its presence must, 
in a large portion of cases, depend on temporary causes, and has not 
always the same serious importance as in the non-pregnant state. This 
is further proved by the undoubted fact that albumen, rapidly disap- 
pearing after delivery, is often found in urine of pregnant women who 
go to term and pass through labor without any unfavorable symptoms. 

Pressure by the Gravid Uterus, — The obvious facts that in pregnancy 
the vessels supplying the kidneys are subjected to mechanical pressure 
from the gravid uterus, and that congestion of the venous circulation 
of those viscera must necessarily exist to a greater or less degree, suggest 
that here we may find an explanation of the frequent occurrence of albu- 
minuria. This view is further strengthened by the fact that the albumen 
rarely appears until after the fifth month, and therefore not until the 
uterus has attained a considerable size; and also that it is comparatively 
more frequently met with in primiparse, in whom the resistance of the 
abdominal parietes, and consequent pressure, must be greater than in 
women who have already borne children. It is indeed probable that 
pressure and consequent venous congestion of the kidneys have an 
important influence in its production; but there must be, a- a rule, some 
other factors in operation, since an equal or even greater amounl of pres- 
sure is often exerted by ovarian and fibroid tumors without any such 
consequences. They are probably complex. One important condition 
is doubtless the increased amount of work the kidneys have t<> <l<> in 
excreting the waste products of the foetus, as well as those of the mother. 
The increased arterial tension throughoul the body, associated with 
hypertrophy of the heart, known to exist in pregnancy, also operafo - in 

1 American Journal of Obstetrics, July, 1878. Bi lin klin, Woch., Sept, 



208 PREGNANCY. 

the same direction. But in the large majority of eases, although these 
conditions are present, no albuminuria exists, and they must therefore 
be looked upon as predisposing causes, to which some other is added 
before the albumen escapes from the vessels. What this is, generally 
escapes our observation, but probably any condition producing sudden 
hyperemia of the kidneys and giving rise to a state analogous to the 
first stage of Bright's disease — such, for example, as sudden exposure to 
cold and impeded cutaneous action — may be sufficient to set a light to 
the match already prepared by the existence of pregnancy. It has more 
recently been pointed out that a transient albuminuria, disappearing in 
a few days, is very common after delivery, and probably depends on a 
catarrhal condition of the urinary tract. Ingersten observed this in 50 
out of 153 deliveries, and in 15 only had any albumen existed before 
the confinement. 1 In addition to these temporary causes it must not be 
forgotten that pregnancy may supervene in a patient already suffering 
from Bright's disease, when, of course, the albumen will exist in the 
urine from the commencement of gestation. 

The Effects of Puerperal Albuminuria. — The various diseases associated 
with the presence of albumen in the urine will require separate consider- 
ation. Some of these, especially puerperal eclampsia, are amongst the 
most dangerous complications of pregnancy. Others, such as paralysis, 
cephalalgia, dizziness, may also be of considerable gravity. The precise 
mode of their production, and Avhether they can be traced, as is generally 
believed, to the retention of urinary elements in the blood, either urea 
or free carbonate of ammonia produced by its decomposition, or whether 
the two are only common results of some undetermined cause, will be con- 
sidered when we come to discuss puerperal convulsions. Whatever view 
may ultimately be taken on these points, it is sufficiently obvious that 
albuminuria in a pregnant Avoman must constantly be a source of much 
anxiety, and must induce us to look forward with considerable appre- 
hension to the termination of. the case. 

Prognosis. — We are scarcely in possession of a sufficiently large 
number of observations to justify any very accurate conclusions as to the 
risk attending albuminuria during pregnancy, but it is certainly by no 
means slight. Hofmier believes that albuminuria is a most severe com- 
plication both for woman and child, even when uncomplicated with 
eclampsia. The prognosis, he thinks, depends on whether it is acute in 
its onset — that is, coming on within a few days of labor — or is extended 
over several weeks. The former is more likely to pass entirely away 
after delivery, while in the latter there is more risk of the morbid state 
of the kidneys becoming permanent and leading to the establishment of 
Bright's disease after the pregnancy is over. Goubeyre estimated that 
49 per cent, of primiparse who have albuminuria, and who escape 
eclampsia, die from morbid conditions traceable to the albuminuria. 
This conclusion is probably much exaggerated, but if it even approxi- 
mate to the truth the danger must be very great. 

Tendency to Produce Abortion. — Besides the ultimate risk to the 
mother, albuminuria strongly predisposes to abortion, no doubt on 
account of the imperfect nutrition of the foetus by blood impoverished 

1 Zeitschrift f. Geburt, Band v. Heft 2. 



DISEASES OF PREGNANCY. 209 

by the drain of albuminous materials through the kidneys. This fact 
has been observed by many writers. A good illustration of it is given 
by Tanner/ who states that four out of seven women he attended 
suffering from Bright's disease during pregnancy aborted, one of them 
three times in succession. 

Symptoms. — The symptoms accompanying albuminuria in pregnancy 
are by no means uniform or constantly present. That which most 
frequently causes suspicion is the anasarca — not only the oedematous 
swelling of the lower limbs which is so common a consequence of the 
pressure of the gravid uterus, but also of the face and upper extremities. 
Any puffiness or infiltration about the face, or any oedema about the 
hands or arms, should always give rise to suspicion and lead to a careful 
examination of the urine. Sometimes this is carried to an exaggerated 
degree, so that there is anasarca of the whole body. 

Nervous Phenomena. — Anomalous nervous symptoms — such as head- 
ache, transient dizziness, dimness of vision, spots before the eyes, in- 
ability to see objects distinctly, sickness in women not at other times 
suffering from nausea, sleeplessness, irritability of temper — are also 
often met with, sometimes to a slight degree, at others very strongly 
developed, and should always arouse suspicion. Indeed, knowing as 
we do that many morbid states may be associated with albuminuria, we 
should make a point of carefully examining the urine of all patients 
in whom any unusually morbid phenomena show themselves during 
pregnancy. 

Character of the Urine. — The condition of the urine varies con- 
siderably, but it is generally scanty and highly colored, and, in addition 
to the albumen, especially in cases in which the albuminuria has existed 
for some time, we may find epithelium-cells, tube-casts, and occasionally 
blood-corpuscles. 

Treatment. — The treatment must be based on what has been said as 
to the causes of the albuminuria. Of course it is out of our power to 
remove the pressure of the gravid uterus, except by inducing labor; 
but its effects may at least be lessened by remedies tending to promote 
an increased secretion of urine, and thus diminishing the congestion of 
the renal vessels. The administration of saline diuretics, such as the 
acetate of potash or bitartrate of potash, the latter being given in the 
form of the well-known imperial drink, will best answer this indication. 
The action of the bowels may be solicited by purgatives producing 
watery motion.-, such as occasional doses of the compound jalap powder. 
Dry cupping over the loins, frequently repeated, has a beneficial effect 
in Lessening the renal hyperemia. The action of the skin should also 
be promoted by the use of the vapor bath, and with this view the 
Turkish bath may be employed with great benefit and perfect safety. 
Jaborandi and pilocarpi!] have been given for this purpose, but have 
been found by Fordvce Barker to produce a dangerous degree of de- 
pression. The next indication is to improve th*' condition of the bl I 

by appropriate diet and medication. A very light and easily-assimilated 
diet should be ordered, of which milk should form the staple. Tarnier 
has recorded several cases in which a purely milk diet was very successful 

1 Signs and Diseases of Pregnancy, p. 428. '-' Annul. </< < inure. Jan., 

14 



210 PREGNANCY. 

in removing albuminuria. With the milk, which should be skimmed, 
we may allow white of egg or a little white fish. The tincture of the 
perchloride of iron is the best medicine we can give, and it may be 
advantageously combined with small doses of tincture of digitalis, which 
acts as an excellent diuretic. 

Question of Inducing Labor. — Finally, in obstinate cases we shall 
have to consider the advisability of inducing premature labor. The 
propriety of this procedure in the albuminuria of pregnancy has of late 
years been much discussed. Spiegelberg 1 is opposed to it, while Barker 2 
thinks it should only be resorted to " when treatment has been thoroughly 
and perseveringly tried without success for the removal of symptoms of 
so grave a character that their continuance would result in the death of 
the patient." Hofmeier, 3 on the other hand, is in favor of the operation, 
which he does not think increases the risk of eclampsia, and may avert 
it altogether. I believe that, having in view the undoubted risks which 
attend this complication, the operation is unquestionably indicated, and 
is perfectly justifiable, in all cases attended with symptoms of serious 
gravity. It is not easy to lay down any definite rules to guide our 
decision ; but I should not hesitate to adopt this resource in all cases 
in which the quantity of albumen is considerable and progressively 
increasing, and in which treatment has failed to lessen the amount, and, 
above all, in every case attended with threatening symptoms, such as 
severe headache, dizziness, or loss of sight. The risks of the operation 
are infinitesimal compared to those which the patient would run in the 
event of puerperal convulsions supervening or chronic Bright's disease 
becoming established. As the operation is seldom likely to be indicated 
until the child has reached a viable age, and as the albuminuria places 
the child's life in danger, we are quite justified in considering the mother's 
safety alone in determining on its performance. 

Diabetes. — The occurrence of pregnancy in a woman suffering from, 
diabetes may lead to serious consequences, and has recently been speci- 
ally investigated by Dr. J. Matthews Duncan. 4 This must be carefully 
distinguished from the physiological glycosuria commonly present at the 
end of pregnancy and during lactation. It is probable that diabetic 
patients are inapt to conceive, but when pregnancy does occur under 
such conditions the case cannot be considered devoid of anxiety. From 
the cases collected by Dr. Duncan it would appear that pregnancy is 
very liable to be interrupted in its course, generally by the death of the 
foetus, which has very often occurred. In some instances no bad results 
have been observed, while in others the patient has collapsed after 
delivery. Diabetic coma does not seem to have been observed. Out 
of twenty-two pregnancies in diabetic women, four ended fatally, so that 
the mortality is obviously very large. Too little is known on this 
subject to justify positive rules of treatment ; but if the symptoms are 
serious and increasing it would probably be justifiable to induce labor 
prematurely, so as to lessen the strain to which the patient's constitution 
is subjected. 

1 Lehrbuch des Geburt. 2 A mer. Journ. of Obstet., July, 1878. 

3 Op. cit. * Obst. Trans., vol. xxiv. 



DISEASES OF PREGNANCY. 211 



CHAPTER VIII. 

DISEASES OF PREGNANCY (CONTINUED). 

Disorders of the Nervous System. — There are many disorders of the 
nervous system met with during the course of pregnancy. Among the 
most common are morbid irritability of temper or a state of mental 
despondency and dread of the results of the labor, sometimes almost 
amounting to insanity or even progressing to actual mania. These are 
but exaggerations of the highly susceptible state of the nervous system 
generally associated with gestation. Want of sleep is not uncommon, 
and, if carried to any great extent, may cause serious trouble from the 
irritability and exhaustion it produces. In such cases we should en- 
deavor to lessen the excitable state of the nerves by insisting on the 
avoidance of late hours, overmuch society, exciting amusements, and the 
like ; while it may be essential to promote sleep by the administration 
of sedatives, none answering so well as the chloral hydrate, in combi- 
nation with large doses of the bromide of potassium or sodium, which 
greatly intensify its hypnotic effects. 

Headaches and Neurcdgice. — Severe headaches and various intense 
neuralgia? are common. Amongst the latter the most frequently met 
with are pain in the breasts, due to the intimate sympathetic connection 
of the mammae with the gravid uterus, and intense intercostal neuralgia, 
which a careless observer might mistake for pleuritic or inflammatory 
pain. The thermometer, by showing that there is no elevation of tem- 
perature, would prevent such a mistake. Neuralgia of the uterus itself 
or severe pains in the groins or thighs — the latter being probably the 
mechanical results of dragging on the attachments of the abdominal 
muscles — are also far from uncommon. In the treatment of such neu- 
ralgic affections attention to the state of the general health, and large 
doses of quinine and ferruginous preparations whenever there is much 
debility, will be indicated. Locally sedative applications, such as bella- 
donna and chloroform liniments, friction with aconite liniment when the 
pain is limited to a small space, and, in the worst cases, the subcutane- 
ous injection of morphia, will be called for. Those pains which appar- 
ently depend on mechanical causes may often be best relieved by lessen- 
ing the traction on the muscles by wearing a well-made elastic belt to 
support the uterus. 

Paralysis depending on Pregnancy. — Among the mosl interesting of 
the nervous diseases are various paralytic affections. Almosl all varieties 
of paralysis have been observed, such as paraplegia, hemiplegia (com- 
plete or incomplete), facial paralysis, and paralysis of the nerves of 
special sense, giving rise to amaurosis, deafness, and loss of taste. 
Churchill records 22 cases of paralysis during pregnancy, collected by 
him from various sources. A large number have also been brought 
together by Imbert Gou bey re in an interesting memoir on the subject, 



212 PREGNANCY. 

and others are recorded by Fordyce Barker, Joulin, and other authors, 
so that there can be no doubt of the fact that paralytic affections are 
common during gestation. In a large proportion of the cases recorded 
the paralyses have been associated with albuminuria, and are doubtless 
ursemic in origin. Thus in 19 cases related by Goubeyre albuminuria 
was present in all ; Darcy, 1 however, found no albuminuria in 5 out 
of 14 cases. The dependency of the paralysis on a transient cause 
explains the fact that in the large majority of these cases the paralysis 
was not permanent, but disappeared shortly after labor. In every case 
of paralysis, whatever be its nature, special attention should be directed 
to the state of the urine, and, should it be found to be albuminous, labor 
should be at once induced. This is clearly the proper course to pursue, 
and we should certainly not be justified in running the risk that must 
attend the progress of a case in which so formidable a symptom has 
already developed itself. When the cause has been removed the effect 
will also generally rapidly disappear, and the prognosis is therefore, on 
the whole, favorable. Should the paralysis continue after delivery, the 
treatment must be such as we would adopt in the non-pregnant state, 
and small doses of strychnia, along with faradization of the affected 
limbs, would be the best remedies at our disposal. 

Paralyses which are not Urmmic in their Origin, — There are, however, 
unquestionably some cases of puerperal paralysis which are not ursemic 
in their origin and the nature of which is somewhat obscure. Hemi- 
plegia may doubtless be occasioned by cerebral hemorrhage, as in the 
non-pregnant state. Other organic causes of paralysis, such as cerebral 
congestion or embolism, may now and again be met with during preg- 
nancy, but cases of this kind must be of comparative rarity. Other 
cases are functional in their origin. Tarnier relates a case of hemiplegia 
which he could only refer to extreme anaemia. Some, again, may be 
hysterical. Paraplegia is apparently more frequently unconnected with 
albuminuria than the other forms of paralysis, and it may either depend 
on pressure of the gravid uterus on the nerves as they pass through the 
pelvis or on reflex action, as is sometimes observed in connection with 
uterine disease. When in such cases the absence of albuminuria is 
ascertained by frequent examination of the urine, there is obviously not 
the same risk to the patient as in cases depending on uraemia, and there- 
fore it may be justifiable to allow pregnancy to go on to term, trusting 
to subsequent general treatment to remove the paralytic symptoms. As 
the loss of power here depends on a transient cause, a favorable prognosis 
is quite justifiable. Partial paralysis of one lower extremity, generally 
the left, sometimes occurs from pressure of the foetal occiput, and 
may continue for days or weeks, with a gradual imj^rovement, after 
parturition. 

Chorea. — Chorea is not unfrequently observed, and forms a serious 
complication. It is generally met with in young women of delicate 
health and in the first pregnancy. In a large proportion of the cases 
the patient has already suffered from the disease before marriage. On 
the occurrence of pregnancy the disposition to the disease again becomes 
evoked and choreic movements are re-established. This fact may be 

1 These de Paris, 1877. 



DISEASES OF PREGNANCY. 213 

explained partly by the susceptible state of the nervous system, partly 
by the impoverished condition of the blood. 

Prognosis. — That chorea is a dangerous complication of pregnancy is 
apparent by the fact that out of oQ cases collected by Dr. Barnes l no less 
than 17, or 1 to 3, proved fatal. Xor is it danger to life alone that is 
to be feared, for it appears certain that chorea is more apt to leave per- 
manent mental disturbance when it occurs during pregnancy than at 
other times. It has also an unquestionable tendency to bring on abor- 
tion or premature labor, and in most cases the life of the child is 
sacrificed. 

Treatment. — The treatment of chorea during pregnancy does not differ 
from that of the disease under more ordinary circumstances, and our 
chief reliance will be placed on such drugs as the liquor arsenicalis, bro- 
mide of potassium, and iron. In the severe form of the disease the 
incessant movements and the weariness and loss of sleep may very seri- 
ously imperil the life of the patient, and more prompt and radical meas- 
ures will be indicated. If, in spite of our remedies, the paroxysms go on 
increasing in severity and the patient's strength appears to be exhausted, 
our only resource is to remove the most evident cause by inducing labor. 
Generally, the symptoms lessen and disappear soon after this is done. 
There can be no question that the operation is perfectly justifiable, and 
may even be essential under such circumstances. It should be borne in 
mind that the chorea often recurs in a subsequent pregnancy, and extra 
care should then always be taken to prevent its development. 

Disorders of the Urinary Organs. — Disorders of the urinary orpins 
are of frequent occurrence. Retention of urine may be met with, 
and this is often the result of a retroverted uterus. The treatment, 
therefore, must then be directed to the removal of the cause. This sub- 
ject will be more particularly considered when we come to discuss that 
form of displacement (p. 216) ; but we may here point out that retention 
of urine, if long continued, may not only lead to much distress, but to 
actual disease of the coats of the bladder. Several eases have been 
recorded in which cystitis, resulting from urinary retention in pregnancy, 
eventually caused the exfoliation of the entire mucous membrane of the 
bladder, 2 which was cast off, sometimes entire, sometimes in shreds, and 
occasionally with portions of the muscular coat attached to it. The 
possibility of this formidable accident should teach us to be careful not 
to allow any undue retention of urine, but by a timely use of the cath- 
eter to relieve the symptoms, while we at the same time endeavor to 
remove the cause. 

Irritability of the Bladder. — Irritability of the bladder is of frequent 
occurrence. In the early months it seem- to he the consequence of 
sympathetic irritation of the neck of the bladder, combined with pres- 
sure, while in the later months it is probably Solely produced by mechan- 
ical causes. When severe it leads to much distress, the patient's rest 
being broken and disturbed by incessant calls to micturate, and the suf- 
fering induced may produce serious constitutional disturbances. I have 
elsewhere pointed out ! that irritability of the bladder in the later months 
of pregnancy is frequently associated with an abnormal position of the 
1 Obst. Trans., vol. x. a Ibid., vol. xi. (bid., vol. xiii. 



214 PREGNANCY. 

foetus, which is placed transversely or obliquely. The result is either 
that undue pressure is applied to the bladder or that it is drawn out of 
its proper position. The abnormal position of the foetus can readily be 
detected by palpation, and is readily altered by external manipulation. 
In some of the cases I have recorded altering the position of the foetus 
was immediately followed by relief, the symptoms recurring after a time 
when the foetus had again assumed an oblique position. Should the 
foetus frequently become displaced, an endeavor may be made to retain 
it in the longitudinal axis of the uterus by a proper adaptation of band- 
ages or pads. In cases not referable to this cause we should attempt to 
relieve the bladder symptoms by appropriate medication, such as small 
doses of liquor potassse if the urine be very acid ; tincture of bella- 
donna ; the decoction of triticum repens, an old but very serviceable 
remedy ; and vaginal sedative pessaries containing morphia or atropine. 

[In one case where a lady had borne two children with very little 
inconvenience I found great suffering from the pressure of the foetus on 
the bladder, commencing as early as the fifth month. This continued 
for a period of two months, when she very fortunately miscarried. In 
making a digital exploration I recognized that the foetus was anencepha- 
lous, and for this reason descended too low in the pelvis. — Ed.] 

Incontinence of Urine. — Women who have borne many children are 
often troubled with incontinence of urine during pregnancy, the water 
dribbling away on the slightest movement. Through this much irrita- 
tion of the skin surrounding the genitals is produced, attended with 
troublesome excoriations and eruptions. Relief may be partially 
obtained by lessening the pressure on the bladder by an abdominal 
belt, while the skin is protected by applications of simple ointment or 
glycerin. 

Phosphatic Deposit. — Dr. Tyler Smith has directed attention to a 
phosphatic condition of the urine occurring in delicate women, whose 
constitutions are severely tried by gestation. This condition can easily 
be altered by rest, nutritious diet, and a course of restorative medicines, 
such as steel, mineral acids, and the like. 

Leucorrhoea. — A profuse whitish leucorrhoeal discharge is very com- 
mon during pregnancy, especially in its latter half. The discharge fre- 
quently alarms the patient, but, unless it is attended with disagreeable 
symptoms, it does not call for special treatment. When at all excessive 
it may lead to much irritation of the vagina and external generative 
organs. The labia may become excoriated and covered with small 
aphthous patches, and the whole vulva may be hot, swollen, and tender. 
Warty growths, similar in appearance to syphilitic condylomata, are 
occasionally developed in pregnant women, unconnected with any specific 
taint and associated with the presence of an irritating leucorrhoeal dis- 
charge. According to Thibierge, 1 these resist local applications, such as 
sulphate of copper or nitrate of silver, but spontaneously disappear after 
delivery. Inasmuch as the leucorrhoeal discharge is dependent on the 
congested condition of the generative organs accompanying pregnancy, 
we can hope to do little more than alleviate it. In tjie severer forms, as 
has been pointed out by Henry Bennet, the cervix will be found to be 

1 Arch. gen. de Med., 1856. 



DISEASES OF PBEGNANOY. 215 

abraded or covered with granular erosion, and it may be from time to 
time cautiously touched with the nitrate of silver or a solution of car- 
bolic acid. Generally speaking, we must content ourselves with recom- 
mending the patient to wash the vagina out gently with diluted Condv's 
fluid, or with a solution of the sulpho-carbolate of zinc of the strength 
of four grains to the ounce of water, or with plain tepid water. For 
obvious reasons, frequent and strong vaginal douches are to be 
avoided, but a daily gentle injection, for the purpose of ablution, can 
do no harm. 

Pruritus. — A very distressing pruritus of the vulva is frequently met 
with along with leucorrhoea, especially when the discharge is of an acrid 
character, which in some cases leads to intense and protracted suffering, 
forcing the patient to resort to incessant friction of the parts. Pruritus, 
however, may exist without leucorrhcea, being apparently sometimes of 
a neuralgic character, at others associated with aphthous patches on the 
mucous membrane, ascarides in the rectum, or pediculi in the hairs of 
the mons veneris and labia. Cases are even recorded in which the pru- 
ritic irritation extended over the whole body. The treatment is difficult 
and unsatisfactory. Various sedative applications may be tried, such as 
weak solutions of Goulard's lotion, or a lotion composed of an ounce of 
the solution of the muriate of morphia, with a drachm and a half of 
hydrocyanic acid, in six ounces of water, or one formed by mixing one 
part of chloroform with six of almond oil. A very useful form of 
medication consists in the insertion into the vagina of a pledget of cot- 
ton wool, soaked in equal parts of the glycerin of borax and sulphurous 
acid ; this may be inserted at bedtime, and withdrawn in the morning 
by means of a string attached to it. Smearing the parts with an oint- 
ment consisting of boracic acid and vaseline often answers admirably. 
In the more obstinate cases the solid nitrate of silver maybe lightly 
brushed over the vulva, or, as recommended by Tarnier, a solution of 
bichloride of mercury, of about the strength of two grains to the ounce, 
may be applied night and morning. The state of the digestive organs 
should always be attended to, and aperient mineral water may be use- 
fully administered. When the pruritus extend- beyond the vulva, or 
even in severe local cases, large doses of bromide of potassium may 
perhaps be useful in lessening the general hypersesthetic -late of the 
nerves. 

(Edema of the Lover Limbs. — Some, of the disorders of pregnancy are 
the direct results of the mechanical pressure of the gravid uterus. The 
most common of these are oedema and a varicose -talc of the veins of the 
lower extremities, or even of the vulva. The former is of little conse- 
quence, provided we have assured ourselves that it is really the resull 
of pressure, and not of albuminuria, and it can generally be relieved 
by rest in the horizontal position. A varicose state of tli<' vein- of tin- 
lower limbs is very common, especially in multipara, in whom it i- apl 
to continue after delivery. Occasionally the vein- of the vulva, and 
even of the vagina, are also enlarged and varicose, producing consider- 
able swelling of the external genitals. Resl in the recumbent position 
and the use of an abdominal belt, so as t<> take the pressure off the veins 
as much as possible, are all that can be done to relieve this trouble- 



216 PREGNANCY. 

some complication. If the veins of the legs are much swollen, some 
benefit may be derived from an elastic stocking or a carefully applied 
bandage. 

Occasional Serious Results from Laceration of the Veins. — Serious and 
even fatal consequences have followed the accidental laceration of the 
swollen veins. When laceration occurs during or immediately after 
delivery— a not uncommon result of the pressure of the head — it gives 
rise to the formation of a vaginal thrombus. It has occasionally hap- 
pened from an accidental injury during pregnancy, as in the cases 
recorded by Simpson, in which death followed a kick on the pudenda, 
producing laceration of a varicose vein, or in one mentioned by Tarnier, 
where the patient fell on the edge of a chair. Severe hemorrhage has 
followed the accidental rupture of a vein in the leg. The only satisfac- 
tory treatment is pressure, applied directly to the bleeding parts by 
means of the finger or by compresses saturated in a solution of the per- 
chloride of iron. The treatment of vaginal thrombus following labor 
must be considered elsewhere. Occasionally the varicose veins inflame, 
become very tender and painful, and coagula form in their canals. In 
such cases absolute rest should be insisted on, while sedative lotions, 
such as the chloroform and belladonna liniments, should be applied to 
relieve the pain. 

Displacements of the Gravid Uterus. — Certain displacements of the 
gravid uterus are met with which may give rise to symptoms of great 
gravity. 

Prolapse, which, is rare, is almost always the result of pregnancy 
occurring in a uterus which had been previously more or less procident. 
Under such circumstances the increasing weight of the uterus will at 
first necessarily augment the previously existing tendency to prolapse of 
the womb, which may come to protrude partially or entirely beyond the 
vulva. In the great majority of cases, as pregnancy advances, the pro- 
lapse cures itself, for at about the fourth or fifth month the uterus will 
rise above the pelvic brim. It has been said that in some cases of com- 
plete procidentia pregnancy has gone even to term with the uterus lying 
entirely outside the vulva, Most probably these cases were imperfectly 
observed, the greater part of the uterus being in reality above the pelvic 
brim, a portion only of its lower segment protruding externally ; or, as 
has sometimes been the case, the protruding portion has been an old- 
standing hypertrophic elongation of the cervix, the internal os uteri and 
fundus being normally situated. ' Should a prolapsed uterus not rise 
into the abdominal cavity as pregnancy advances, serious symptoms will 
be apt to develop themselves ; for, unless the pelvis be unusually capa- 
cious, the enlarging uterus will get jammed within its bony walls, the 
rectum and urethra will be pressed upon, defecation and micturition 
will be consequently impeded, and severe pain and much irritation will 
result, In all probability such a state of things would lead to abortion. 
The possibility of these consequences should therefore teach us to be 
careful in the management of every case of prolapse, however slight, in 
which pregnancy occurs. Absolute rest in the horizontal position 
should be insisted on, while the uterus should be supported in the pelvis 
by a full-sized Hodge's pessary, which should be worn until at least the 



DISEASES OF PREGNANCY. 217 

sixth month, when the litems would be fully within the abdominal cav- 
ity. After delivery prolonged rest should be recommended, in the hope 
that the process of involution may be accompanied by a cure of the pro- 
lapse. There can be no doubt that pregnancy carried to term affords an 
opportunity of curing even old-standing displacements which should not 
be neglected. 

Anteversion of the gravid uterus seldom produces symptoms of conse- 
- quence. In all probability it is common enough when pregnancy occurs 
in a uterus which is more than usually anteverted or is anteflexed. 
Under such circumstances there is not the same risk of incarceration in 
the pelvic cavity as in cases in which pregnancy exists in a retroflexed 
uterus, for as the uterus increases in size it rises without difficulty into 
the abdominal cavity. In the early months the pressure of the fundus 
on the bladder may account for the irritability of that viscus then so 
commonly observed. It will be remembered that Graily Hewitt attrib- 
utes great importance to this condition as explaining the sickness 
of pregnancy — a theory, however, which has not met with general 
acceptation. 

Extreme anteversion of the uterus at an advanced period of pregnancy 
is sometimes observed in multipara? with very lax abdominal walls, occa- 
sionally to such an extent that the uterus falls completely forward and 
downward, so that the fundus is almost on a level with the patient's 
knees. This form of pendulous belly may be associated with a separa- 
tion of the recti muscles, between which the womb forms a ventral hernia, 
covered only by the cutaneous textures. When labor comes on, this 
variety of displacement may give rise to trouble by destroying the proper 
relation of the uterine and pelvic axes. The treatment is purely mechani- 
cal, keeping the patient lying on her back as much as possible and sup- 
porting the pendulous abdomen by a properly adjusted bandage. A 
similar forward displacement is observed in cases of pelvic deformity, 
and in the worst forms, in rachitic and dwarfed women, it exists to a 
very exaggerated degree. 

Retroversion. — The most important of the displacements, in conse- 
quence of its occasional very serious results, is retroversion of the gravid 
uterus. It was formerly generally believed that this was most commonly 
produced by some accident, such as a fall, which dislocated a uterus pre- 
viously in a normal position. Undue distension of the bladder was also 
considered to have an important influence in its production by pressing 
the uterus backward and downward. 

Its ('liases. — It is now almost universally admitted that, although the 
above-named causes may possibly sometimes produce it, in the very large 
proportion of cases it depends on pregnancy having occurred in a uterus 
previously retroverted or retroflexed. The merit of pointing out this 
tact unquestionably belongs to the late Dr. Tyler Smith, and further 
observations have fully corroborated the correctness of his views. 

In the large majority of cases in which pregnancy occurs in a uterus 
so displaced, as the womb enlarges it straightens itself and pises into the 
abdominal cavity, without giving any particular trouble; or, as not 
unfrequently happens, the abnormal position of the organ interferes so 
much with its enlargement as to produce abortion. Sometimes, how 



218 PREGNANCY. 

the uterus increases without leaving the pelvis until the third or fourth 
month, when it can no longer be retained in the pelvic cavity without 
inconvenience. It then presses on the urethra and rectum, and eventu- 
ally becomes completely incarcerated within the rigid walls of the bony 
pelvis, giving rise to characteristic symptoms. 

Symptoms. — The first sign which attracts attention is generally some 
trouble connected with micturition in consequence of pressure on the 
urethra. On examination the bladder will often be found to be enor- 
mously distended, forming a large, fluctuating abdominal tumor, which 
the patient has lost all power of emptying. Frequently small quantities 
of urine dribble away, leading the woman to believe that she has passed 
water, and thus the distension is often overlooked. Sometimes the 
obstruction to the discharge of urine is so great as to lead to dropsical 
eifusion into the cellular tissue of the arms and legs. This was very 
well marked in one of my cases, and disappeared rapidly after the blad- 
der had been emptied. Difficulty in defecation, tenesmus, obstinate con- 
stipation, and inability to empty the bowels become established about 
the same time. These symptoms increase, accompanied by some pelvic 
pain and a sense of weight and bearing down, until at last the patient 
applies for advice and the true nature of the case is detected. When 
the retroversion occurs suddenly, all these symptoms develop with great 
rapidity, and are sometimes very serious from the first. 

Progress and Termination. — The further progress is various. Some- 
times, after the uterus has been incarcerated in the pelvis for more or 
less time, it may spontaneously rise into the abdominal cavity, when all 
threatening symptoms will disappear. So happy a termination is quite 
exceptional, and if the practitioner should not interfere and effect reposi- 
tion of the organ, serious and even fatal consequences may ensue unless 
abortion occurs. 

Termination if Reduction is not Effected. — The extreme distension of 
the bladder, and the impossibility of relieving it, may lead to lacerations 
of its coats and fatal peritonitis ; or the retention of urine may produce 
cystitis, with exfoliation of the coats of the bladder ; or, as more com- 
monly happens, retention of urinary elements may take place, and death 
occur with all the symptoms of ursemic poisoning. At other times the 
impacted uterus becomes congested and inflamed, and eventually sloughs, 
its contents, if the patient survive, being discharged by fistulous com- 
munications into the rectum and vagina, It need hardly be said that 
such terminations are only possible in cases which have been grossly mis- 
managed or the nature of which has not been detected till a late period. 

Diagnosis. — The diagnosis is not difficult. On making a vaginal 
examination the finger impinges on a smooth, round, elastic swelling, 
filling up the lower part of the pelvis, stretching and depressing the pos- 
terior vaginal wall, which occasionally protrudes beyond the vulva. On 
passing the finger forward and upward we shall generally be able to 
reach the cervix, high up behind the pubes and pressing on the urethral 
canal. In very complete retroversion it may be difficult or impossible 
to reach the cervix at all. On abdominal examination the fundus uteri 
cannot be felt above the pelvic brim : this, as the retroversion does not 
give rise to serious symptoms until between the third and fourth months, 



DISEASES OF PREGNANCY. 219 

should, under natural circumstances, always be possible. By bi-manual 
examination we can make out, with due care, the alternate relaxation 
and contraction of the uterine parietes characteristic of the gravid uterus, 
and so differentiate the swelling from any other in the same situation. 
The accompanying phenomena of pregnancy will also prevent any mis- 
take of this kind. 

Retroversion going on to Term. — In some few cases retroversion has 
been supposed to go on to term. Strictly speaking, this is impossible ; 
but in the supposed examples, such as the well-known case recorded 
by Oldliam, part of a retroflexed uterus remained in the pelvic cavity, 
while the greater part developed in the abdominal cavity. The uterus 
is therefore divided, as it were, into two portions — one, which is the 
flexed fundus, remaining in the pelvis ; the other, containing the greater 
part of the foetus, rising above it. Under these circumstances a tumor 
in the vagina would exist in combination with an abdominal tumor, and 
pregnancy might go on to term. Considerable difficulty may even arise 
in labor, but the malposition generally rectifies itself before it gives rise 
to any serious results. 

Treatment. — The treatment of retroversion of the gravid uterus should 
be taken in hand as soon as possible, for every day's delay involves an 
increase in the size of the uterus, and therefore greater difficulty in 
reposition. Our object is to restore the natural direction of the uterus 
by lifting the fundus above the promontory of the sacrum. The first 
thing to be done is to relieve the patient by emptying the bladder, the 
retention of urine having probably originally called attention to the case. 
For this purpose it is essential to use a long elastic male catheter of small 
size, as the urethra is too elongated and compressed to admit of the pas- 
sage of the ordinary silver instrument. Even then it may be extremely 
difficult to introduce the catheter, and sometimes it has been found to be 
quite impossible. Under such circumstances, provided reposition cannot 
be effected without it, the bladder may be punctured an inch or two 
above the pubes by means of the fine needle of an aspirator, and the 
urine drawn off. Dieulafoy's work on aspiration proves conclusively 
that this may be done without risk, and the operation has been success- 
fully performed by Schatz and others. It very rarely happens, however, 
and in long-neglected cases only, that the withdrawal of the urine is 
found to be impossible. 

Mode of Effecting Reduction. — The bladder being emptied, and the 
bowels being also opened, if possible, by copious enemata, we proceed 
to attempt reduction. For this purpose various procedure- are adopted. 
If the ease is not of very long standing, I am inclined to think thai the 
gentlest and safes! plan is the continuous pressure of a caoutchouc bag, 
filled with water, placed in the vagina. The good effed of steady and 
long-continued pressure of this kind was proved by Tyler Smiih. who 
effected in this way the reduction of an inverted uterus of long standing, 
and it is not dillicult to understand that it may succeed when a more 
sudden and violent effort fails. I have tried this plan successfully in 
two cases, a pyriform india-rubber bag being inserted into the vagina 
and distended as far as the patient could bear by mean- of a syringe. 
The water must be let out occasionally to allow the patienl to empty 



220 PREGNANCY. 

the bladder, and the bag immediately refilled. In both my cases repo- 
sition occurred within twenty-four hours. Barnes has failed with this 
method, but it succeeded so well in my cases, and is so obviously less 
likely to prove hurtful than forcible reposition with the hand, that I 
am inclined to consider it the preferable procedure, and one that should 
be tried first. Failing with the fluid pressure, we should endeavor to 
replace the uterus in the following way : The patient should be placed 
at the edge of the bed, in the ordinary obstetric position, and thoroughly 
anaesthetized. This is of importance, as it relaxes all the parts and 
admits of much freer manipulation than is otherwise possible. One or 
more fingers of the left hand are then inserted into the rectum — if the 
patient be deeply chloroformed, it is quite possible, with due care, even 
to pass the whole hand — and an attempt is then made to lift or push the 
fundus above the promontory of the sacrum. At the same time repo- 
sition is aided by drawing down the cervix with the fingers of the right 
hand per vaginam. It has been insisted that the pressure should be 
made in the direction of one or other sacro-iliac synchondrosis rather 
than directly upward, so that the uterus may not be jammed against 
the projection of the promontory of the sacrum. Failing reposition 
through the rectum, an attempt may be made per vaginam, and for this 
some have advised the upward pressure of the closed fist passed into the 
canal. Others recommend the hand-and-knee position as facilitating 
reposition, but this prevents the administration of chloroform, which is 
of more assistance than any change of position can possibly be. Various 
complex instruments have been invented to facilitate the operation, but 
they are all more or less dangerous, and are unlikely to succeed when 
manual pressure has failed. 

As soon as the reduction is accomplished, subsequent descent of the 
uterus should be prevented by a large-sized Hodge's pessary, and the 
patient should be kept at rest for some days, the state of the bladder 
and bowels being particularly attended to. When reposition has been 
fairly effected a relapse is unlikely to occur. 

Treatment when Reduction is found Impossible. — In cases in which 
reduction is found to be impossible our only resource is the artificial 
induction of abortion. Under such circumstances this is imperatively 
called for. It is best effected by puncturing the membranes, the dis- 
charge of the liquor amnii of itself lessening the size of the uterus, and 
thus diminishing the pressure to which the neighboring parts are sub- 
jected. After this reposition may be possible, or we may wait until the 
foetus is spontaneously expelled. It is not always easy to reach the os 
uteri, although we can generally do so with a curved uterine sound. If 
we cannot puncture the membranes, the liquor amnii may be drawn off 
through the uterine walls by means of the aspirator, inserted through 
either the rectum or vagina. The injury to the uterine walls thus 
inflicted is not likely to be hurtful, and the risk is certainly far less 
than leaving the case alone. Naturally, so extreme a measure would 
not be adopted until all the simpler means indicated have been tried 
and failed. 

Diseases Coexisting with Pregnancy. — The pregnant woman is of 
course liable to contract the same diseases as in the non-pregnant state, 



DISEASES OF PREGNANCY. 221 

and pregnancy may occur in women already the subject of some consti- 
tutional disease. There is no doubt yet much to be learned as to the 
influence of coexisting disease on pregnancy. It is certain that some 
diseases are but little modified by pregnancy, and that others are so to 
sl considerable extent, and that the influence of the disease on the foetus 
varies much. The subject is too extensive to be entered into at any 
length, but a few words may be said as to some of the more important 
affections that are likely to be met with. 

Eruptive Fevers: Small-pox. — The eruptive fevers have often very 
serious consequences, proportionate to the intensity of the attack. Of 
these variola has the most disastrous results, which are related in the 
writings of the older authors, but which are, fortunately, rarely seen in 
these days of vaccination. The severe and confluent forms of the dis- 
ease are almost certainly fatal to both the mother and child. In the 
discrete form and in modified small-pox after vaccination the patient 
generally has the disease favorably, and although abortion frequently 
results, it does not necessarily do so. 

Scarlet Fever. — If scarlet fever of an intense character attacks a preg- 
nant woman, abortion is likely to occur and the risks to the mother are 
very great. The milder cases run their course without the production 
of any untoward symptoms. Should abortion occur, the well-known 
dangerous effect of this zymotic disease after delivery will gravely influ- 
ence the prognosis. Cazeaux was of opinion that pregnant women are 
not apt to contract the disease, while Montgomery thought that the 
poison when absorbed during pregnancy might remain latent until 
delivery, when its characteristic effects were produced. 

Measles. — Measles, unless very severe, often runs its course without 
seriously affecting the mother or child. I have myself seen several 
examples of this. De Tourcoing, however, states that out of 15 cases 
the mother aborted in 7, these being all very severe attacks. Some 
cases are recorded in which the child was born with the rubeolous erup- 
tion upon it. 

Continued Fevers. — The pregnant woman may be attacked with any 
of the continued fevers, and, if they are at all severe, they are apt to 
produce abortion. Out of 22 cases of typhoid, 16 aborted, and the 
remaining 6, who had slight attacks, went on to term ; out of 63 cases 
of relapsing fever, abortion or premature labor occurred in 23. Accord- 
ing to Sell weden, the main cause of danger to the foetus in continued 
fevers is the hyperpyrexia, especially when the maternal temperature 
reaches 104° or upward. The fevers do not appear to be aggravated as 
regards the mother, and the same observation has been made by ( azeanx 
with regard to this class of disease occurring alter delivery. 

Pneumonia. — Pneumonia seems to be specially dangerous, for of L5 
cases collected by Grisolle, 1 11 died — a mortality immensely greater than 
that of the disease in general. The larger proportion also aborted, the 
children being generally dead, and the fatal result is probably due, as in 
the severe continued level's, to hyperpyrexia, The cause of the mater- 
nal mortality does not seem quite apparent, since the same danger <\<"- not 
-appear to exist in severe bronchitis or other inflammatory affections. 

1 Arch. gen. de Mid-, vol. xii. p. 291. 



222 PREGNANCY. 

Phthisis. — Contrary to the usually-received opinion, it appears cer- 
tain that pregnancy has no retarding influence on coexisting phthisis, 
nor does the disease necessarily advance with greater rapidity after 
delivery. Out of 27 cases of phthisis collected by Grisolle, 1 24 showed 
the first symptoms of the disease after pregnancy had commenced. 
Phthisical women are not apt to conceive — a fact which may probably 
be explained by the frequent coexistence in such cases of uterine disease, 
especially severe leucorrhcea. The entire duration of the phthisis seems 
to be shortened, as it averaged only nine and a half months in the 27 
cases collected — a fact which proves, at least, that pregnancy has no 
material influence in arresting its progress. If we consider the tax on 
the vital powers which pregnancy naturally involves, we must admit 
that this view is more physiologically probable than the one generally 
received, and apparently adopted without any due grounds. 

Heart Disease. — The evil effects of pregnancy and parturition on 
chronic heart disease have of late received much attention from Spiegel- 
berg, Fritsch, Peter, and other writers. The subject has been ably dis- 
cussed 2 in a series of elaborate papers by Dr. Angus McDonald, which are 
well worthy of study. Out of 28 cases collected by him, 17, or 60 per 
cent., proved fatal. This, no doubt, is not altogether a reliable estimate 
of the probable risk of the complication, but, at any rate, it shows the 
serious anxiety which the occurrence of pregnancy in a patient suffering 
from chronic heart disease must cause. Dr. McDonald refers the evils 
resulting from pregnancy in connection with cardiac lesions to two 
causes : first, destruction of that equilibrium of the circulation which 
has been established by compensatory arrangements ; secondly, the 
occurrence of fresh inflammatory lesions upon the valves of the heart 
already diseased. 

The dangerous symptoms do not usually appear until after the first 
half of the pregnancy has passed, and the pregnancy seldom advances 
to term. The pathological phenomena generally met with in fatal cases 
are pulmonary congestion, especially of the bronchial mucous membrane, 
and pulmonary oedema, with occasional pneumonia and pleurisy. Mitral 
stenosis seems to be the form of cardiac lesion most likely to prove 
serious, and next to this aortic incompetency. The obvious deduction 
from these facts is, that heart disease, especially when associated with 
serious symptoms, such as dyspnoea, palpitation, and the like, should be 
considered a strong contraindication of marriage. When pregnancy has 
actually occurred, all that can be done is to enjoin the careful regulation 
of the life of the patient, so as to avoid exposure to cold and all forms 
of severe exertion. 

Syphilis. — The important influence of syphilis on the ovum is fully 
considered elsewhere. As regards the mother, its effects are not different 
from those at other times. It need only, therefore, be said that when- 
ever indications of syphilis in a pregnant woman exist the appropriate 
treatment should be at once instituted and carried on during her gesta- 
tion, not only with the view of checking the progress of the disease, but 
in the hope of preventing or lessening the risk of abortion or of the 
birth of an infected infant. So far from pregnancy contraindicating 

1 Arch. yen. de Med., vol. xxii. 2 Obst. Journ., 1877. 



DISEASES OF PREGNANCY. 223 

mercurial treatment, there rather is a reason for insisting on it more 
strongly. As to the precise medication, it is advisable to choose a form 
that can be exhibited continuously for a length of time without pro- 
ducing serious constitutional results. Small doses of the bichloride of 
mercury, such as one-sixteenth of a grain, thrice daily, or of the iodide 
of mercury, or of the hydrargyrum cum creta, in combination with 
reduced iron, answer this purpose well ; or in the early stages of 
pregnancy the mercurial vapor bath or cutaneous inunction may be 
employed. 

Dr. Weber of St. Petersburg 1 has made some observations showing 
the superiority of the latter methods, which he found did not interfere 
with the course of pregnancy; the contrary was the case when the 
mercury was administered by the mouth, probably, as he supposes, from 
disturbance of the digestive system. It must be borne in mind that in 
married women it may sometimes be expedient to prescribe an anti- 
syphilitic course without their knowledge of its nature, so that inunction 
is not always feasible. 

Epilepsy. — The influence of pregnancy on epilepsy does not appear 
to be as uniform as might perhaps be expected. In some cases the 
number and intensity of the fits have been lessened ; in others the 
disease becomes aggravated. Some cases are even recorded in which 
epilepsy appeared for the first time during gestation. On account 
of the resemblance between epilepsy and eclampsia there is a natural 
apprehension that a pregnant epileptic may suffer from convulsions 
during delivery. Fortunately, this is by no means necessarily the case, 
and labor often goes on satisfactorily without any attack. 

Jaundice, the result of acute yellow atrophy of the liver, is occa- 
sionally observed, and is said to have been sometimes epidemic. In- 
dependently of the grave risks to the mother, it is most likely to pro- 
duce abortion or the death of the foetus. According to Davidson, 2 it 
originates in catarrhal icterus, the excretion of the bile-products being 
impeded in consequence of pregnancy, and their retention giving rise 
to the fatal blood-poisoning which accompanies the severer forms of the 
disease. Slight and transient attacks of jaundice may occur without 
being accompanied by any bad consequences. Their production is 
probably favored by the mechanical pressure of the gravid uterus on 
the intestines and the bile-ducts. 

( hrdnoma. — The occurrence of pregnancy in a woman suffering from 
malignant disease of the uterus is by no means so rare as mighl be sup- 
posed, and must naturally give rise to much anxiety as to the result. 
The obstetrical treatment of these cases will be discussed elsewhere. 
Should we be aware of the existence of the disease during gestation, the 
question will arise whether we should not attempt to lessen the risks of 
delivery by bringing on abortion or premature labor. The question is one 
which is by no means easy to settle. We have to deal with a disease which 
is certain to prove fatal to the mother before long, and the progress of 
which is probably accelerated after labor, while the manipulations neces- 
sary to induce delivery nun- very unfavorably influence the diseased 
structures. Again, by such a measure we necessarily sacrifice the child, 
1 Alhjom. Med Cent. Zeit., Feb., 1875. Monat.f. Qebvrt, 1867. 



224 PREGNANCY. 

while we are by no means certain that we materially lessen the danger 
to the mother. The question cannot be settled except on a consideration 
of each particular case. If we see the patient early in pregnancy, by 
inducing abortion we may save her the dangers of labor at term — possi- 
bly of the Cesarean section — if the obstruction be great. Under such 
circumstances the operation would be justifiable. If the pregnancy has 
advanced beyond the sixth or seventh month, unless the amount of 
malignant deposit be very small indeed, it is probable that the risks of 
labor would be as great to the mother as at term, and it would then 
be advisable to give her the advantage of the few months' delay. 

Ovarian Tumor. — Cases are occasionally met with in which preg- 
nancy occurs in women who are suffering from ovarian tumor, and their 
proper management has given rise to considerable discussion. There 
can be no doubt that such cases are attended with very dangerous and 
often fatal consequences, for the abdomen cannot well accommodate the 
gravid uterus and the ovarian tumor, both increasing simultaneously. 
The result is that the tumor is subject to much contusion and pressure, 
which have sometimes led to the rupture of the cyst and the escape of 
its contents into the peritoneal cavity ; at others to a low form of inflam- 
mation, attended with much exhaustion, the death of the patient super- 
vening' either before or shortly after delivery. The danger during deliv- 
ery from the same cause in the cases which go on to term is also very 
great. Of 13 cases of delivery by the natural powers, which I collected 
in a paper on " Labor Complicated with Ovarian Tumor," l far more 
than one-half proved fatal. [In one instance in this city a lady well 
known to the editor gave birth to three of her four children during the 
existence of an ovarian tumor. The children all lived to grow up, and 
their mother died of her disease at the age of 75, after being repeatedly 
tapped during fifty years. The ovarian tumor was discovered by Dr. 
Benjamin Rush soon after her first child was born in 1809, and she was 
first tapped by Dr. Physick in 1811. In 1812, 1815, and 1818 she 
gave birth to the children mentioned, the third being delicate, sickly, 
and weighing six pounds. This last died of phthisis when 45 ; one still 
lives. 2 According to the teaching of Mr. Lawson Tait, this may have 
been a parovarian cyst, and not an ovarian cystoma. — Ed.] Another 
source of danger is twisting of the pedicle, and consequent strangulation 
of the cyst, of which several instances are recorded. It is obvious, then, 
that the risks are so manifold that in every case it is advisable to con- 
sider whether they can be lessened by surgical treatment. 

Methods of Treatment. — The means at our disposal are either to induce 
labor prematurely, to treat the tumor by tapping, or to perform ovari- 
otomy. The question has been particularly discussed by Spencer Wells 
in his works on Ovariotomy, and by Barnes in his Obstetric Operations. 
The former holds that the proper course to pursue is to tap the tumor 
when there is any chance of its being materially lessened in size by that 
procedure, but that when it is multilocular or when its contents are solid 
ovariotomy should be performed at as early a period of pregnancy as 
possible. Barnes, on the other hand, maintains that the safer course is 

1 Obst. Trans., vol. ix. 

[ 2 Trans. Phila. Obstet. Soc, vol. i., 1873, p. 64, reported by Ed.] 



DISEASES OF PREGNANCY. 225 

to imitate the means by which nature often meets this complication, and 
bring on premature labor without interfering with the tumor. He thinks 
that ovariotomy is out of the question, and that tapping may be insuf- 
ficient and leave enough of the tumor to interfere seriously with labor. 
So far as recorded cases go, they unquestionably seem to show that tap- 
ping is not more dangerous than at other times, and that ovariotomy 
may be j^ractised during pregnancy with a fair amount of success. Wells 
records 10 cases which were surgically interfered with. In 1 tapping 
was performed, and in 9 ovariotomy ; and of these 8 recovered, the preg- 
nancy going on to term in 5. On the other hand, 5 cases were left alone, 
and either went to term or spontaneous premature labor supervened ; and 
of these 3 died. The cases are not sufficiently numerous to settle the 
question, but they certainly favor the view taken by Wells rather than 
that by Barnes. It is to be observed that unless we give up all hope 
of saving the child and induce abortion, the risk of induced premature 
labor, when the pregnancy is sufficiently advanced to hope for a viable 
child, would almost be as great as that of labor at term ; for the ques- 
tion of interference will only have to be considered with regard to large 
tumors, which would be nearly as much affected by the pressure of a 
gravid uterus at seven or eight months as by one at term. Small tumors 
generally escape attention, and are more apt to be impacted before the 
presenting part in delivery. The success of ovariotomy during preg- 
nancy has certainly been great, and we have to bear in mind that the 
woman must necessarily be subjected to the risk of the operation sooner 
or later, so that we cannot judge of the case as one in which abortion ter- 
minates the risk. Even if the operation should put an end to the preg- 
nancy — and there is at least a fair chance that it will not do so — there is 
no certainty that that would increase the risk of the operation to the 
mother, while as regards the child we should only have the same result 
as if we intentionally produced abortion. On the whole, then, it seems 
that the best chance to the mother, and certainly the best to the child, is 
to resort to the apparently heroic practice recommended by Wells. The 
determination must, however, be to some extent influenced by the skill 
and experience of the operator. If the medical attendant has not gained 
that experience which is so essential for a successful ovariotomist, the 
interests of the mother would be best consulted by the induction of abor- 
tion at as early a period as possible. One or other procedure is essentia] ; 
for, in spite of a few cases in which several successive pregnancies have 
occurred in women who have had ovarian tumors, the risks are such as 
not to justify an expectant practice. Should rupture of the cyst occur, 
there can be no doubt that ovariotomy should at once be resorted to, 
with the view of removing the lacerated cyst and its extravasated 
contents. 

Fibroid Tumors. — Pregnancy may occur in a uterus iu which there 
are one or more fibroid tumors, li' these are situated low down and in 
a position likely to obstruct the passage of the foetus, they may very 
seriously complicate delivery. When they are situated iu the fundus or 
body of the uterus they may give rise to risk from hemorrhage or from 
inflammation of their own structure. Inasmuch as they are structurally 
similar to the uterine walls, they partake of the growth of the uterus 

15 



226 PREGNANCY. 

during pregnancy, and frequently increase remarkably in size. Cazeaux 
says : " I have known them in several instances to acquire a size in three 
or four months which they would not have done in several years in the 
non-pregnant condition/' Conversely, they share in the involution of 
the uterus after delivery, and often lessen greatly in size, or even entirely 
disappear. Of this fact I have elsewhere recorded several curious exam- 
ples ; l and many other instances of the complete disappearance of even 
large tumors have been described by authors whose accuracy of observa- 
tion cannot be questioned. 

Treatment. — The treatment will vary with the position of the tumor. 
If it is such as to be certain to obstruct the passage of the child, abor- 
tion should be induced as soon as possible. If the tumor is well out 
of the way, this is not so urgently called for. The principal danger, 
then, is that the tumor will impede the post-partum contraction of the 
uterus and favor hemorrhage. Even if this should happen, the flooding 
could be controlled by the usual means, especially by the injection of the 
perchloride of iron. I have seen several cases in which delivery has 
taken place under such circumstances without any untoward accident. 
The danger from inflammation and subsequent extrusion of the fibroid 
masses would probably be as great after abortion or premature labor as 
after delivery at term. It seems, therefore, to be the proper rule to inter- 
fere when the tumors are likely to impede delivery, and in other cases 
to allow the pregnancy to go on, and be prepared to cope with any com- 
plications as they arise. The risks of pregnancy should be avoided in 
every case in which uterine fibroids of any size exist, the patients being 
advised to lead a celibate life. 

[Fibroid tumors may so obstruct the pelvis as to make delivery per 
vias naturales impossible. If the obstacle cannot be forced up out of the 
pelvis with the hand, delivery by the abdomen will be required if the 
child is to be saved. This form of obstruction makes the Csesarean 
operation more than usually hazardous, and likewise its modification by 
Porro. Ten Csesarean operations have been performed in consequence 
of obstruction by uterine fibroids in the United States, with the saving 
of four women and five children. Two fatal Porro operations have also 
been performed. — Ed.] 



CHAPTER IX. 

PATHOLOGY OF THE DECIDUA AND OVUM. 

Pathology of the Decidua. — Comparatively little is, unfortunately, 
known of the pathological changes which occur in the mucous mem- 
brane of the uterus during pregnancy. It is probable that they are of 
much more consequence than is generally believed to be the case, and it 
is certain that they are a frequent cause of abortion. 

1 Obst. Trans., vols, v., xiii., and xix. 



PATHOLOGY OF THE DECIDUA AXD OVUM. 



227 



Endometritis. — One of the most generally observed probably depends 
on endometritis antecedent to conception. When the impregnated ovule 
reached the uterus it engrafted itself on the inflamed mucous membrane, 
which was in an unfit condition for its reception and growth. A not 
uncommon result, under such circumstances, is the laceration of some of 
the decidual vessels, extravasation of the blood between the decidua and 
the uterine walls, and consequent abortion at an early stage of preg- 
nancy. As this morbid state of the uterine mucous membrane is likely 
to continue after abortion is completed, the same history repeats itself 
on each impregnation, and thus we may have constant early miscarriages 
produced. It does not necessarily follow, however, that the pregnancy 
is immediately terminated when this state of things is present. Sonie~ 

Fig. 87. 




Hypertrophied Decidua laid open, with the Ovum attached to its Fundal Portion. 
(After Duncan. i 

times a condition of hyperplasia of the decidua is produced, the mem- 
brane becomes much thickened and hypertrophied in consequence of 
proliferation of its interstitial connective tissue, and the decidual cells 
are greatly increased in size (Fig. 87). In other instances the internal 
surface of the decidua become- studded with rough polypoid growths, 1 
depending on proliferation of its interstitial tissue. Duncan has found 
that the hypertrophied decidua is always in a state of fatty degeneration, 
more advanced in some places than in other-.- The result of these alter- 
1 Virchow's Archh.fiir Path.. L861, 1st ed. - Researches in Obsteb , p, 



228 PREGNANCY. 

ations is frequently to produce dwindling or death of the ovum, which, 
however, retains its connection with the decidua, until, after a lapse of 
time, the decidua is expelled in the form of a thick triangular fleshy sub- 
stance, with the atrophied ovum attached to some part of its inner sur- 
face. In other cases, in which the hyperplasia has advanced to a less 
extent, the nutrition of the foetus is not interfered with, and pregnancy 
may continue to term, the changes in the decidua being recognizable after 
delivery. Other diseases besides endometritis may give rise to similar 
alterations in the decidua, one of these being, as Virchow maintains, 
syphilis. The converse condition, an imperfect development of the 
decidua, especially of the decidua reflexa, has also been noted as a cause 
of abortion. The ovum will then hang loosely in the uterine cavity, 
without the support which the growth of the decidua reflexa around it 
ought to afford, and its premature expulsion readily follows (Fig. 88). 

Fig. 88. 




Imperfectly developed Decidua Vera, with the Ovum. (After Duncan.) 

Hydrorrhoea Gravidarum. — The peculiar condition known as hydror- 
rhea gravidarum most probably depends on some obscure morbid state 
of the uterine mucous membrane. By it is meant a discharge of clear 
watery fluid at intervals during pregnancy. It may happen at any pe- 
riod of gestation, but is most commonly met with in the latter months. 
It may commence with a mere dribbling, or there may be a sudden and 
copious discharge of fluid. Aftenvard the watery fluid, which is gener- 
ally of a pale yellowish color and transparent like the liquor amnii, may 
continue to escape at intervals for many weeks,* and sometimes in very 
great abundance, so as to saturate the patient's clothes. Very frequently 
it is expelled in gushes, and at night when the patient is lying quietly in 
bed ; its escape is then probably due to uterine contraction. 

Many theories have been held as to its cause. By some it is attributed 
to the rupture of a cyst placed between the ovum and the uterine walls ; 
Baudelocque referred it to a transudation of the liquor amnii through 
the membranes ; while Burgess and Dubois believed it to depend on a 



PATHOLOGY OF THE DECLDUA AXD OVUM. 229 

laceration of the membranes at a distance from the os uteri. Mattei 
more recently has attributed it to the existence of a sac between the chorion 
and the amnion. It may be that in some instances a single discharge of 
fluid may come from one of the two last-mentioned causes. But if it 
be continuous or repeated another source must be sought for. Hegar 1 
maintains that it is the result of abundant secretion from the glands of 
the mucous membrane, which accumulates between the decidua and chorion 
and escapes through the os uteri. If this occur, the decidua is probably 
in a hypertrophied and otherwise morbid state. Hydrorrhoea is chiefly 
of interest from the error of diagnosis it is likely to giye rise to, for on 
being; summoned to a case in which watery discharge has occurred for 
the first time, we are naturally apt to suppose that the membranes haye 
ruptured and that labor is imminent. Xor is there any very certain 
means of deciding if this be so. In hydrorrhoea we find that pains are 
absent, the os uteri unopened, and ballottement may be made out. Eyen 
if the membranes be ruptured, there will be no indication for interference 
unless labor has actually commenced ; and the repetition of the discharge 
and the continuance of the pregnancy will soon clear up the diagnosis. 
Hydrorrhoea, although apt to alarm the patient, need not giye rise to any 
anxiety. The pregnancy generally progresses favorably to the full period, 
although in exceptional cases premature labor may supervene. No 
treatment is necessary, nor is there any that could have the least effect 
in controlling the discharge. 

Pathology of the Chorion. — The only important disease of the chorion 
with which we are acquainted is the well-known condition which is vari- 
ously described as uterine hydatids, cystic disease of the ovum, hydatidi- 
form degeneration of the chorion, or vesicular mole. The name of uterine 
hydatids was long given to it on the supposition that the grape-like vesi- 
cles which characterize the disease were true hydatids, similar to those 
which develop in the liver and other structures. This idea has long 
been exploded, and it is now known as a certainty that the disease orig- 
inates in the villi of the chorion. The precise mode and the causes of 
its production are, however, not yet satisfactorily settled. The disease is 
characterized by the existence in the cavity of the uterus of a large num- 
ber of translucent vesicles containing a clear limpid fluid, which has 
been found on analysis to bear close resemblance 4 to the liquor amnii. 
These small bladder-like bodies, which vary in size from that of a millet- 
seed to an acorn, are often described as resembling a bunch of grapes or 
currants. On more minute examination they are found not to be each 
attached to independent pedicles, as is the ease in a hunch of grapes, hut 
some of them grow from other vesicles, while others have distinct pedi- 
cles attached to the chorion, the pedicles themselves sometimes being dis- 
tended by fluid (Fig. 89). This peculiar arrangement of the vesicles is 
explained by their mode of growth. 

Causes of Cystic Degeneration. — There has been considerable disCUS- 
sion as to the etiology of this disease. By some it is supposed always 
to follow death of the fetus, and, the whole developmental energy being 
expended on the chorion, which retains its attachment to the decidua, 
the result is its abnormal growth and cystic degeneration. This is th< 

1 Mount, f. Grbin/, 1863. 



230 



PREGNANCY. 



view maintained by Gierse and Graily Hewitt, and it is favored by the 
undoubted fact that in almost all- cases the foetus has entirely disap- 
peared, and by the occasional occurrence of cases of twin conceptions in 
which one chorion has degenerated, the other remaining healthy until 

term. On the other hand, it is maintained 
that the starting-point is connected with the 
maternal organism. Virchow thinks it orig- 
inates in a morbid state of the decidua, while 
others have attributed it to some blood-dys- 
crasia on the part of the mother, such as 
syphilis. There are many reasons for be- 
lieving that causes of this nature may orig- 
inate the affection. Thus it is often found to 
occur more than once in the same person, 
and alterations of a similar kind, although 
limited in extent, are not unfrequently found 
in connection with the placenta and mem- 
branes of living children. On this theory 
the death of the fcetus is secondary, the con- 
sequence of impaired nutrition from the mor- 
bid state of the chorion. The probability 
is that both views may be right, the disease 
sometimes following the death of the embryo, 
and at others being the result of obscure ma- 
ternal causes. 

Its Pathology. — The degeneration of the 
chorion villi generally commences at an early 
period of pregnancy, before the placenta has 
commenced to form. In that case the entire superficies of the chorion 
becomes affected. The disease, however, may not begin until after the 
greater part of the chorion villi have atrophied, and then it is limited to 
the placenta. The epithelium of the villi appears to be the part first 
affected, and the whole interior of the diseased villus becomes filled with 
cells. The connective tissue of the villus undergoes a remarkable pro- 
liferation, and collects in masses at individual spots, the remainder of 
the villus being unaffected. By the growth of these elements the villus 
becomes distended and many of the cells liquefy, the intercellular fluid 
thus produced widely separating the connective tissue, so as to form a 
network in the interior of the villus. 1 Thus are formed the peculiar 
grape-like bodies which characterize the disease. When once the degen- 
eration has commenced, the diseased tissue has a remarkable power of 
increase, so that it sometimes forms a mass as large as a child's head and 
several pounds in weight. 

The nutrition of the altered chorion is maintained by its connections 
with the decidua, which is also generally diseased and hypertrophied. 
Sometimes the adhesion of the mass to the uterine walls is very firm, 
and may interfere with its expulsion, while in a few rare cases it has 
been found that the villi have forced their way into the substance of the 
uterus, chiefly through the uterine sinuses, and thus caused atrophy and 

1 Braxton Hicks, Guy's Hospital Report*, vol. ii., 3d Series, p. 380. 




Hydatidiform Degeneration of the 
Chorion. 



PATHOLOGY OF THE DECIDUA AND OVUM. 231 

thinning of its muscular structure. Cases of this kind are related by 
Volkniann, Waldeyer, 1 and Barnes, and it is obvious that the intimate 
adhesion thus effected must seriously add to the gravity of the prognosis. 

Taking this view of the etiology of this disease, it is obvious that it 
is essentially connected with pregnancy, and that there is no valid ground 
for maintaining, as has sometimes been done, that it may occur inde- 
pendently of conception. It is just possible, however, that true entozoa 
may form in the substance of the uterus, which, being expelled per vagi- 
nam, might be taken for the results of cystic disease, and thus give rise 
to groundless suspicions as to the patient's chastity. Hewitt has related 
one case in which true hydatids, originally formed in the liver, had 
extended to the peritoneum, and were about to burst through the vagina 
at the time of death. This occurred in an unmarried woman. One or 
two other examples of true hydatids forming in the substance of the 
uterus are also recorded. A very interesting case is also related by 
Hewitt 2 in which undoubted acephalocysts were expelled from the uterus 
of a patient who ultimately recovered. A careful examination of the 
cyst and its contents would show their true nature, as the echinococci 
heads, with their characteristic hooklets, would be discoverable by the 
microscope. 

It is also possible that unfounded suspicions might arise from the fact 
of a patient expelling a mass of hydatids long after impregnation. In 
the case of a widow or woman living apart from her husband serious 
mistakes might thus be made. This has been specially pointed out by 
McClintock, 3 who says : " Hydatids may be retained in utero for many 
months or years, or a portion only may be expelled, and the residue may 
throw out a fresh crop of vesicles, to be discharged on a future occasion. " 

Symptoms and Progress of the Disease. — The symptoms of cystic dis- 
ease of the ovum are by no means w T ell marked. At first there is noth- 
ing to point to the existence of any morbid condition, but as pregnancy 
advances its ordinary course is interfered with. There is more general 
disturbance of the health than there ought to be, and the reflex irrita- 
tions, such as vomiting, may be unusually developed. The first physical 
sign remarked is rapid increase of the uterine tumor, which soon does 
not correspond in size to the supposed period of pregnancy. Thus, at 
the third month the uterus may be found to reach up to or beyond the 
umbilicus. About this time there generally are more or less profuse 
watery and sanguineous discharges, which have been described as resem- 
bling currant-juice. They no doubt depend on the breaking down and 
expulsion of the cysts, caused by painless uterine contractions. They 
are sometimes excessive in amount, recur witli great frequency, and often 
reduce the patient extremely. Portions of cysts may now generally be 
found mingled with the discharge, and sometimes large masses of them 
are expelled from time to time. Indeed, the discovery of portions of 
cysts is the only certain diagnostic sign. Vaginal examination, before 
the os has dilated, will give no information except the absence of bal- 

lottement. An unusual hardness or density of the iitern described by 

Leishman, who attributes much importance to it, as "a peculiar doughy, 

1 Virchov/a Archiv, vol. xliv. p. 86. ■ Obs. Trans., vol. xii. 

:; McClintock'a Diseases of Women, p. 



232 PREGNANCY. 

boggy feeling " — has been pointed out by several writers. The contour of 
the uterine tumor, moreover, is often irregular. In addition, we of course 
fail to discover the usual auscultatory signs of pregnancy. All this may 
aid in diagnosis, but nothing except the presence of cysts in the watery 
bloody discharge will enable us to pronounce with certainty as to the 
nature of the disease. 

Treatment. — As soon as the diagnosis is established the indications for 
treatment are obvious. The sooner the uterus is cleared of its contents 
the better. Ergot may be given with advantage to favor uterine con- 
traction and the expulsion of the diseased ovum. Should this fail, 
more especially if the hemorrhage be great, the fingers or the whole hand 
must be introduced into the uterus, and as much as possible of the mass 
removed. As the os is likely to be closed, its preliminary dilatation by 
sponge or laminaria tents, or by a Barnes's bag if it be already opened 
to some extent, will in most cases be required. If chloroform be then 
administered, the remaining steps of the operation will be easy. On 
account of the occasional firm adhesion of the cystic mass to the uterus, 
too energetic attempts at complete separation should be avoided. Any 
severe hemorrhage after the operation can be controlled by swabbing out 
the uterine cavity with the perchloride of iron solution. 

Myxoma Fibrosum. — Under the name of Myxoma fibrosum a more 
rare degeneration of the chorion has been described by Virchow and 
Hildebrandt, 1 characterized not by vesicular but by fibroid degeneration 
of the connective tissue of the chorion. This is, however, too little 
understood to require further observation. 

Pathology of the Placenta. — The pathology of the placenta has of late 
years attracted much attention, and it has an important practical bear- 
ing, in consequence of its effect on the child. 

Placentae vary considerably in shape. They may be crescentic, or 
spread over a considerable surface, in consequence of the chorion villi 
entering into communication with a larger portion of the decidua than 
usual (placenta membranacea). Such forms, however, are merely of 
scientific interest. The only anomaly of shape of any practical import- 
ance is the formation of what have been called placentce suceenturice. 
These consist of one or more separate masses of placental tissue, pro- 
duced by the development of isolated patches of chorion villi. Hohl 
believes that they always form exactly at the junction of the anterior 
and posterior walls of the uterus, which in early pregnancy is a mere 
line. As the uterus expands, the portions of placenta on each side of 
this become separated from each other. They are only of consequence 
from the possibility of their remaining unnoticed in the uterus after 
delivery and giving rise to secondary post-partum hemorrhage. The 
rare form of double placenta with a single cord, figured in the accom- 
panying woodcut (Fig. 90), was probably formed in this way, and the 
supplementary portion in such a case might readily escape notice. 

The placenta may also vary in dimensions. Sometimes it is of 
excessive size, generally when the child is unusually big, but not unfre- 
quently in connection with hydramnios, the child being dead and shriv- 
elled. In other cases it is remarkably small, or at least appears to be 
1 Monat.f. Geburt, May, 1865. 



PATHOLOGY OF THE DECLDUA AXD OVUM. 233 

so. If the child be healthy, this is probably of no pathological import- 
ance, as its smallness may be more apparent than real, depending on its 
vessels not being distended with blood. When true atrophy of the pla- 
centa exists, the vitality of the foetus may be seriously interfered with. 
This condition may depend either on a diseased state of the chorion villi 

Fig. 90. 




Double Placenta, with Single Cord. 

or of the decidua in which they are implanted. 1 The latter is the more 
common of the two; and it generally consists in hyperplasia of the con- 
nective tissue of the decidua, which presses on the villi and vessels and 
gives rise to general or local atrophy. This change is similar in its 
nature to that observed in cirrhosis of the liver and certain forms of 
Blight's disease. It has generally been ascribed to inflammatory 
changes, and under the name of placentitis has been described by many 
authors, and has been considered to be a common disease. To it are 
attributed many of the morbid alterations which are commonly observed 
in placentae, such as hepatizations, circumscribed purulenl deposits, and 
adhesions to the uterine walls. Many modern pathologists have doubted 
whether these changes are in any proper sense inflammatory. Whit- 
taker observes on this point : "The disposition to reject placentitis alto- 
gether increases in modern times. Indeed, it is impossible to conceive 
of inflammation on the modern theory (Cohnheim) of thai process, since 
there are no capillaries, in the maternal portion at least, through whose 
walls a i migration ' might occur, and there are no nerves to regulate the 
contractility of the vessel walls in the entire structure." Robin thus 

1 Whittaker, Amer. Journ. of Obst., vol. iii. p. 229. 



234 



PREGNANCY. 



explains the various pathological changes above alluded to : " What has 
been taken for inflammation of the placenta is nothing else than a con- 
dition of transformation of blood-clots at various periods. What has 
been regarded as pus is only fibrin in the course of disorganization , and 
in those cases where true pus has been found the pus did not come from 
the placenta, but from an inflammation of the tissue of the uterine ves- 
sels and an accidental disposition in the tissue of the placenta." The 
extravasations of blood here alluded to are of very common occurrence, 
and they are found in all parts of the organ — in its substance, on its 
decidual surface, or immediately below the amnion, where they serve as 
points of origin for the cysts that are there often observed. The fibrin 
thus deposited undergoes retrograde metamorphosis, as in other parts of 
the body ; it becomes decolorized, it undergoes fatty degeneration, or it 
becomes changed into calcareous masses ; and in this way, it is sup- 
posed, may be explained the various pathological changes which are so 
commonly observed. The amount of retrograde metamorphosis, and 
the precise appearance presented, will of course depend on the time that 
has elapsed since the blood-extravasations took place. 

Fatty Degeneration. — Fatty degeneration of the placenta, and its 

Fig. 91. 




Fatty Degeneration of the Placenta. 



influence on the nutrition of the foetus, have been specially studied in 
this country by Barnes and Druitt, Yellowish masses of varying sizes 
are very commonly met with in placentae, and these are found to consist, 
in great part, of molecular fat, mixed with a fine network of fibrous tis- 
sue. The true fatty degeneration, however, specially affects the chorion 



PATHOLOGY OF THE DECIDE A ASH OVUM. 



235 



villi (Fig. 91). On microscopic examination they are found to be 
altered and misshaped in their contour and to be loaded with fine gran- 
ular fat-globules. Similar changes are observed in the cells of the 
decidua. The influence on the foetus will, of course, depend on the 
extent to which the functions of the villi are interfered with. The 
probable cause of this degeneration is no doubt some obscure alteration 
in the nutrition of the tissue, depending on the state of the mother's 
health. Barnes believes that syphilis has much influence in its produc- 
tion. Druitt has pointed out that some amount of fatty degeneration is 
always present in a mature placenta, and is probably connected with the 
physiological separation of the organ ; and Goodell has more recently 
suggested that an unusual amount of this change may be merely an 
anticipation of the natural termination of the life of the placenta. 1 

Other Morbid States. — Other morbid states of the placenta, of greater 
rarity, are occasionally met with, as an cedematous infiltration of its tis- 
sue, always occurring, according to Lange, in cases of hydramnios, 
pigmentary and calcareous deposits, and tumors of various kinds ; but 
these require only a passing mention. 

Pathology of the Umbilical Cord. — The umbilical cord may be of 
excessive length, varying from 18 to 20 inches, which is its average 
measurement, up to 50 or 60 inches, and a case is recorded in which it 
even reached the extraordinary length of 9 feet. If unusually long, it 
may be twisted round the limbs or neck of the child, and the latter posi- 
tion may, in exceptional instances, prove injurious during labor. 

Some authors refer cases of spontaneous amputation of foetal limbs in 
utero to constrictions by the umbilical cord, but this accident is more 
probably produced by filamentous adnexa 
of the amnion. Knots in the cord are not 
uncommon, and they result from the foetus, 
in its movements, passing through a loop 
of the cord (Fig. 92). If there is an aver- 
age amount of Wharton's jelly in the cord, 
the vessels are protected from pressure, and 



Fig 



no 



bad 



effects follow, tiery, in a recent 
paper on this subject, 2 attempts to show 
that such knots are more important than 
is generally believed, and relates two cases 
in which he believes them to have caused 
the death of the foetus. 

Extreme torsion of the cord, an exagge- 
ration of the spiral twists generally observed, 
may prove injurious, and even fatal, to the 
child, by obstructing the circulation in the 
vessels. Spaeth mentions three cases in 
which this caused the death of the foetus, 
the cord being twisted until it was reduced 
to the thickness of a thread. 

Anomalies in the distribution of the ves- 
sels of the cord are of common occurrence. 




Knots of tin- f'inl 



The cord may be attached 



1 American Journal of Obstetrics, vol. ii. p. 535. ' E Union medicate, Oct., 1876. 



236 PREGNANCY. 

to the edge, instead of to the centre, of the placenta (battledore 'placenta). 
It may break up into its component parts before reaching the placenta, 
the vessels running through the membranes ; and if, in such a case, 
traction on the cord be made, the separate vessels may lacerate and the 
cord become detached. There may be two veins and one artery, or only 
one vein and one artery, or there may be two separate cords to one pla- 
centa. These and other anomalies that might be mentioned are of little 
practical importance. 

Pathology of the Amnion. — The principal pathological condition of 
the amnion with which we are acquainted is that which is associated 
with excessive secretion of the liquor amnii, and is generally known 
under the name of hydramnios, which term Kidd 1 limits to cases in 
which more than two quarts of amniotic fluid exist. Its precise cause 
is still a matter of doubt. By some it is referred to inflammation of the 
amnion itself; at other times it is apparently connected with some 
morbid state of the decidua, which may be found diseased and hyper- 
trophied. The foetus is very often dead and shrivelled and the placenta 
enlarged and oedematous. It does not necessarily follow, however, that 
hydramnios causes the death of the child. Out of 33 cases, McClintock 
found that 9 children were born dead, 2 and of the 24 born alive, 10 died 
within a few hours ; the remainder survived. There does not appear to 
be any marked relation between the state of the mother's health and the 
occurrence of this disease ; and it is certainly not necessarily present 
when the mother is suffering from dropsical effusions in other parts of 
the body. The theory that the disease is of purely local origin is 
favored by the fact that when hydramnios occurs in twin pregnancy one 
ovum only is generally affected. Its effects, as regards the mother, are 
chiefly mechanical. It rarely begins to show itself before the fifth or 
sixth month of pregnancy, but when once it has commenced it rapidly 
produces a feeling of discomfort and enlargement altogether beyond that 
which should exist at the period of pregnancy which has been reached. 
In advanced stages the distress produced is often very great, the en- 
larged uterus pressing upon the diaphragm and producing much embar- 
rassment of respiration. Premature expulsion of the foetus very often 
supervenes. Four out of McClintock's patients died after labor, show- 
ing that the maternal mortality is high — a result which he refers to the 
debilitated state of the women who were the subjects of the disease. 

Its Diagnosis. — The diagnosis is not, as a rule, difficult. It has to 
be distinguished from ascitic distension of the abdomen, from enlarge- 
ment of the uterus from twin pregnancy, and from ovarian tumor or 
pregnancy complicated with ovarian tumor. The first will be recog- 
nized by the superficial position of the fluid ; by the difficulty of feeling 
the contour of the uterus, which is obscured by the surrounding fluid, 
and the results of percussion, which show that the fluid is free in the 
peritoneal cavity ; and by the coexistence of dropsical effusions in other 
parts of the body. The second may be difficult, and even impossible, 
to diagnose from it : generally, however, in hydramnios the uterine 

1 "On the Diagnosis of Dropsy of the Amnion," Proceedings of the Obstetrical Society 
of Dublin, May 11, 1878. 

2 Diseases of Women, p. 383. 



PATHOLOGY OF THE DECIDUA AND OVUM. 237 

tumor is more distinctly tense or fluctuating, the foetal limbs cannot be 
felt on palpation, and the lower segment of the uterus, as felt per 
vaginam, is unusually distended, the presenting part not being appre- 
ciable. Ovarian tumors alone or complicating pregnancy may also be 
difficult to distinguish from dropsy of the amnion. The general history 
of the case, and the presence or absence of signs of pregnancy, may 
enable us to arrive at a diagnosis ; and Kidd points out that the posi- 
tion of the uterus, whether gravid or not, is usually low down in the 
pelvis in ovarian dropsy, while in dropsy of the amnion it is drawn high 
up and reached with difficulty on vaginal examination. 

Its Effect on Labor. — During labor an excessive amount of liquor 
amnii is often a cause of deficient uterine action and delay, the pains 
being feeble and ineffective. This, of course, tells chiefly in the first 
stage, which is often much prolonged, unless the membranes are punc- 
tured early and the superabundant fluid allowed to escape. 

Treatment. — No treatment is known to have any effect on the disease. 
If the discomfort and distension are very great, it may be absolutely 
necessary to puncture the membranes and allow the water to escape. 
This inevitably brings on labor. If the pregnancy be not sufficiently 
advanced to give hope for the birth of a living child, we would not of 
course resort to this expedient unless the mother's health was seriously 
imperilled. It is possible that in such cases the patient might be 
relieved by inserting the minute needle of an aspirator through the 
os and removing a certain quantity of the liquor amnii by aspiration, 
without inducing the labor. I have never had an opportunity of trying 
this expedient, but it seems a possibility. 

Deficiency of Liquor Amnii. — A defective amount of liquor amnii is 
said to favor certain malformations by allowing the uterus to compress 
the foetus unduly. It certainly occasionally gives rise to adhesion 
between the foetus and the membranes, and to the formation of amni- 
otic bands which are capable of producing certain foetal deformities (pp. 
235 and 240). 

Appearance of the Liquor Amnii. — The liquor amnii itself varies 
much in appearance. It is sometimes thick and treacly, instead of 
limpid, and it may be offensive in odor. The cause of these variations 
is not well understood. 

Pathelogy of the Foetus. — There is abundant evidence that the foetus 
in utero is subject to many diseases, some of which cause its death, and 
others leave distinct traces of their existence, although not proving fatal. 
The subject is of great importance, and is well worthy of study. There 
is still much to he done in this direction which may lend to important 
practical results. I can, however, do little more than enumerate some 
of the principal affections which have been observed. 

Blood Diseases transmitted through the Mother: Siiuill-po.v. — It is a 

well-established fact that the various eruptive levers from which the 
mother may suffer may be communicated to the foetus in utero. When 
the mother Is attacked with confluent small-pox she almost always 
aborts, but not necessarily so when it is discrete or modified. In such 
cases it has often happened that the foetus has been bora with evident 
marks of small-pox. Cases arc on record which prove that the foetus 



238 PREGNANCY. 

was attacked subsequently to the mother. Thus a mother attacked with 
small-pox has miscarried, and has given birth to a living child showing 
no trace of the disease, which, however, showed itself in two or three 
days — proving that it had been contracted, and had run through its 
usual period of incubation, when the foetus was still in utero. It does 
not follow, however, that the foetus is affected, as Serres has collected 22 
cases in which women suffering from small-pox gave birth to children 
Avho had not contracted the disease. It has been supposed that in such 
cases the child is protected from small-pox, though it has shown no 
symptom of having had the disease. Tarnier, however, cites two 
instances in which such children had small-pox two years after birth. 
Madge and Simpson record cases in which vaccination performed on 
the mother during pregnancy protected the foetus, on whom all subse- 
quent attempts at vaccination failed. There is evidence also to prove 
that the disease may be transmitted to the foetus through a mother who 
is herself unsusceptible of contagion, the child having been covered with 
small-pox eruption, the mother being quite free from it. It is probable 
that the same facts which have been observed with regard to small-pox 
hold true with reference to other zymotic diseases, such as scarlet fever 
and measles, although there is not sufficient evidence to justify a posi- 
tive assertion to that effect. 

Malaria and Lead-Poisoning. — Amongst other maternal diseases, 
malaria and lead-poisoning are known to affect the foetus in utero. Dr. 
Stokes relates cases in which the mother suffered from tertian ague, the 
child having also attacks, as evidenced by its convulsive movements, appre- 
ciable by the mother, which took place at the regular intervals, but at a 
different time from the mother's paroxysms. In other cases the febrile 
paroxysm comes on at the same time in the foetus as in the mother ; and 
the fact has been verified by the observation that the paroxysms con- 
tinued to recur simultaneously after delivery. The foetus has also been 
born with distinct malarious enlargement of the spleen. From the fre- 
quency with which largely hypertrophied spleens are seen in mere infants 
in malarious districts, I imagine that the intra-uterine disease must be 
common. I have frequently observed this fact in India, although, of 
course, without any possibility of ascertaining if the mothers had suf- 
fered from intermittent fever during pregnancy. Lead-poisoning is also 
known to have a most prejudicial effect on the foetus, and frequently to 
lead to abortion. M. Paul has collected 81 cases 1 in which it caused 
the death of the foetus, in some not until after birth ; and occasionally it 
seems to have affected the foetus even when the mother escaped. 

Syphilis. — Of all blood-dyscrasise transmitted to the foetus, the most 
important is syphilis. Its influence in producing repeated abortion will 
be elsewhere described (p. 247). It may unquestionably be transmit- 
ted to the foetus without producing abortion, and at term the mother 
may be either delivered of a living child bearing evident traces of the 
disease, of a dead child similarly affected, or of an apparently healthy 
child in whom the disease develops itself after a lapse of a month or 
two. These varying effects probably depend on the intensity of the 
poison ; and the longer the time that has elapsed since the origin of the 

1 Arch. <jeii. de Med., 1860. 



PATHOLOGY OF THE DECIDUA AXD OVUM. 239 

disease in the affected parents, the better will be the chance for the child. 
The disease is no doubt generally transmitted through the mother, and 
if she be affected at the time of conception, the infection of the foetus 
seems certain. If, however, she contracts the disease at an advanced 
period of pregnancy, the child may entirely escape. Ricord even believes 
that syphilis, contracted after the sixth month of pregnancy, never affects 
the child. The father alone may transmit the disease to the ovum ; and 
Hutchinson has recorded cases to show that the mother may become sec- 
ondarily affected through the diseased foetus. The evidences of syphil- 
itic taint in a living or dead child are sufficiently characteristic. The 
child is generally puny and ill-developed. An eruption of pemphigus 
is common, either fully developed bullae or their early stage, when they 
form circular copper-colored patches. This eruption is always most 
marked on the hands and feet, and a child born with such an eruption 
may be certainly considered syphilitic. On post-mortem examination 
the most usual signs are small patches of suppuration in the thymus, 
similar localized suppurations in the tissues of the lungs, indurated yel- 
lowish patches in the liver, and peritonitis, the importance of which in 
causing the death of syphilitic children has been specially dwelt on by 
Simpson. 1 

Inflammatory Diseases. — The most important of the inflammatory 
diseases affecting the foetus is peritonitis. Simpson has shown that traces 
of it are very frequently met with, and that it is not always syphilitic. 
Sometimes it has been observed when the mother has been in bad health 
during pregnancy, and at others it seems to have resulted from some 
morbid condition of the foetal viscera. Pleurisy with effusion is another 
inflammatory affection which has been noticed. 

Dropsies. — The dropsical affections most generally met with arc ascites 
and hydrocephalus, which may both have the effect of impeding delivery. 
Of these, hydrocephalus is the more common, and may give rise to much 
difficulty in labor. Its causes are uncertain, but it probably depends on 
some altered state of the mother's health, as it is apt to recur in several 
successive pregnancies, and is not infrequently associated with an imper- 
fectly developed vertebral column and spina bifida. The fluid collects 
in the ventricles, which it greatly distends, and these then produce expan- 
sion and thinning of the cranium, the bones of which arc widely sepa- 
rated from each other at the sutures, which are prominent and fluctuat- 
ing. In a few cases internal hydrocephalus may be complicated, and 
the diagnosis in labor consequently obscured by the coexistence of what 
has been called " external hydrocephalus." This consists of a collection 
of fluid between the skull and the scalp, which may he either formed 
there originally or may collect from a rupture of one of the suture- or 
fontanelles during labor, through which the intracranial fluid escapes. 

Ascites is generally associated with hvdramnios, and sometimes with 
hydrothorax or other dropsical effusions. It is a rare affection, and 
according to Depaul 2 extreme distension of the bladder is not infre- 
quently mistaken for it. 

Tumors. — Tumors of different kind- may he met with in various parts 
of the child's body, which sometimes grow to a great size and impede 
1 Obzt. Works, vol. i. p. 117. 2 Tanner's Cateaux, p. -'>'>. 



240 



PREGNANCY. 



delivery. Tarnier records cases of meningocele larger than a child's 
head, and large cystic growths have been observed attached to the nates, 
pectoral region, or other parts of the body. Cancerous tumors of con- 
siderable size, either external or of the viscera, have also been met with. 
Other foetal tumors may be produced by congenital deformities, such as 
projection of the liver or other abdominal viscera through a deficiency 
of the abdominal wall ; or spina bifida from imperfectly developed verte- 
brae. The amount of dystocia produced by such causes will, of course, vary 
much in proportion to the size, consistency, and accessibility of the tumor. 
Wounds and Injuries of the Foetus. — Accidents of serious gravity to 
the foetus may happen from violence to which the mother has been sub- 
jected, such as falls or blows, without necessarily interfering with gesta- 
tion. Many curious examples of this kind are on record. Thus, a child 
has been born presenting a severe lacerated wound extending the whole 
length of the spine, where both the skin and the muscles had been torn, 
and which seems to have resulted from the mother having fallen in the 
last month of pregnancy. Similar lacerations and contusions have been 
observed in other parts of the body, the wounds being in various stages 
of cicatrization corresponding to the lapse of time since the accident had 
occurred. Intra-uterine fractures are not rare, apparently arising from 
similar causes. In some of these cases the broken ends of the bones 
had united, but, from want of accurate apposition, at an acute angle, so 
as to give rise to much subsequent deformity. Chaussier records two 
cases in which there were many fractures in the same child, in one 113 
and in another 42, which were in different stages of repair. He attrib- 
utes this curious occurrence to some congenital defect in the nutrition of 
the bones, possibly allied to mollities ossium. 1 

Intra-uterine Amputations of Fodal Limbs. — Intra-uterine amputa- 
tions of foetal limbs have not unfrequently been observed. Children 

are occasionally born with one extremity more 
or less completely absent, and cases are known 
in which the whole four extremities were want- 
ing (Fig. 93). The mode in which these mal- 
formations are produced has given rise to much 
discussion. At one time it was supposed that 
the deficiency of the limb was due to gangrene 
of the extremity and subsequent separation of 
the sphacelated parts. Reuss, who has studied 
the whole subject very minutely, 2 considers 
gangrene in the unruptured ovum to be an 
impossibility, for that change cannot occur 
unless there is access of oxygen, and when 
portions of the separated extremity are found 
in utero, as is often the case, they show evi- 
dences of maceration, but not of decomposi- 
tion. The general belief is that these intra- 
uterine amputations depend on constriction of 
the limb by folds or bands of the amnion — 
most often met with when the liquor amnii is deficient in quantity — 

1 Gazette hebdom., 1860. 2 Scanzoni's Beitrage, 1869. 



Fig. 93. 




Intra-uterine Amputation of 
both Arms and Legs. 



PATHOLOGY OF THE BECLDUA AND OVUM. 241 

which obstruct the circulation and thus give rise to atrophy of the part 
below the constriction. It has been supposed that the umbilical cord 
might, by encircling the limb, produce a like result. It appears doubt- 
ful, however, whether this cause is sufficient to produce complete sepa- 
ration of the limb, as any great amount of constriction would interfere 
with the circulation through the cord. Sometimes, when intra-uterine 
amputation occurs, the separated portion of the limb is found lying loose 
in the amniotic cavity, and is expelled after the child. Cases of this 
kind have been recorded by Martin, Chaussier, and Watkinson. More 
often no trace of the separated extremity can be found. The explana- 
tion probably depends upon the period of utero-gestation at which ampu- 
tation took place. If it occurred at a very early period of pregnancy, 
before the third month, the detached portion would be minute and soft, 
and would easily disappear by solution. If at a later period, this could 
hardly happen, and the detached portion would remain in utero. In 
cases of the latter kind cicatrization of the stump has often been observed 
to be incomplete. Simpson pointed out the occasional existence of rudi- 
mentary fingers or toes on the stump of an amputated limb, such as are 
seen on the thighs in Fig. 93. These he attributed to an abortive repro- 
duction of the separated extremity, analogous to what is observed in 
some of the lower animals. This explanation has been contested with 
much show of reason. Martin believes that the reproduction is only 
apparent, and that the rudimentary extremities are, in reality, instances 
of arrested development. The constricting agents interfered with the 
circulation sufficiently to arrest the growth of the limb below the site 
of constriction, but not sufficiently to effect complete separation. If 
constriction occurred at a very early stage of development, an appear- 
ance similar to that observed by Simpson would be produced. It does 
not follow, however, that all cases of absence of limbs depend on intra- 
uterine amputations. In some cases they would appear to be the result 
of a spontaneous arrest of development or of congenital monstrosity. 
Mr. Scott 1 relates a case in which a distinct hereditary tendency was 
evident, and here the deformity certainly could not have resulted from 
the constriction of amniotic bands. In this family the grandfather had 
both forearms wanting, with rudimentary fingers attached ; the next 
generation escaped, but the grandchild had a deformity precisely similar 
to the grandfather. 

Death of Foetus. — When from any cause the foetus has died during 
pregnancy, it may be either soon expelled or it may be retained in utero 
for a longer or snorter time, or even to the full period. The changes 
observed in such foetuses vary considerably according to the age of the 
foetus at the time of death or the time that it has been retained in utero. 
If it die at an early period, when the tissues are very soft, it may entirely 
dissolve in the liquor amnii, and no trace of it may be found when the 
membranes are expelled. Or it may shrivel or mummify; and if this 
happen in a twin pregnancy, as sometimes occurs, the growing foetus may 
Compress and flatten the dead one against the uterine wall. 

Appearance of a I } nfri<! Foetus. — At a later period of pregnancy a 
dead foetus undergoes changes ascribed to putrefaction, but which pro- 

1 Obnt. Tram., vol. xiii. \>. 94. 
16 



242 PREGNANCY. 

duce appearances different from those of decomposition in animal textures 
exposed to the atmosphere. There is no offensive smell, as in ordinary 
decay. The tissues are all softened and flaccid. The more manifest 
changes are in the skin, the epidermis of which is separated from the 
cutis vera, which has a deep reddish color. This is especially apparent 
on the abdomen, which is flaccid and hollow in the centre. The internal 
organs are much altered. The brain is diffluent and pulpy, and the 
cranial bones loose within the scalp. The structures of the muscles and 
viscera are in various stages of transformation, many having undergone 
fatty changes, and contain crystals of margarin and cholesterin. The 
extent to which these changes occur depends, in a great measure, on the 
length of time the foetus has been dead, but they do not admit of our 
estimating with any degree of accuracy what that time has been. 

Symptoms and Diagnosis of the Death of the Foetus. — The symptoms 
and diagnosis of the death of the foetus may here be considered. They 
are, unfortunately, not very reliable. The cessation of the foetal move- 
ments cannot be depended on, as they are frequently unfelt for days or 
weeks when the child is alive and well. Sometimes the death of the 
foetus is preceded by its irregular and tumultuous movements, and in 
women who have been delivered of several dead children in succession 
this sensation may guide us in our diagnosis. This suspicion may be 
confirmed by auscultation. The mere fact that we are unable, at any 
given time, to hear the foetal heart will not justify an opinion that the 
foetus is dead. If, however, the foetal heart has been distinctly heard, 
and after one or two careful examinations, repeated at separate times, it 
cannot again be made put, the probability of the child being dead may 
be assumed. Certain changes in the mother's health have been noted in 
connection with the death of the foetus, such as depression and lowness 
of spirits, a feeling of coldness and weight about the lower parts of the 
abdomen, paleness of the face, a livid circle round the eyes, irregular 
shiverings and feverishness, shrinking of the breasts, and diminution in 
the size of the abdominal tumor. All these, however, are too indefinite 
to justify a positive diagnosis, and they are not infrequently altogether 
absent. At most they can do no more than cause a suspicion as to what 
has happened. 



CHAPTER X. 

ABORTION AND PREMATURE LABOR. 

Importance and Frequency of Abortion. — The premature expulsion of 
the foetus is an event of great frequency. The number of foetal lives 
thus lost is enormous. There are few multipara? who have not aborted 
at one time or other of their lives. Hegar estimates that about 1 abor- 
tion occurs to every 8 or 10 deliveries at term. Whitehead has calcu- 



ABORTION AND PREMATURE LABOR. 243 

lated that at least 90 per cent, of married women who lived to the change 
of life had aborted. The influence of this incident on the future health 
of the mother is also of great importance. It rarely, indeed, proves 
directly fatal, but it often produces great debility from the profuse loss 
of blood accompanying it ; and it is one of the most proline causes of 
uterine disease in after-life, possibly because women are apt to be more 
careless during convalescence than after delivery, and the proper invo- 
lution of the uterus is thus more frequently interfered with. 

Definition. — A not uncommon division of the subject is into abortion, 
miscarriage, and premature labor, the first name being applied to expul- 
sion of the ovum before the end of the fourth month of utero-gestation ; 
miscarriage, to expulsion from the end of the fourth to the end of the 
sixth month ; and premature labor, to expulsion from the end of the 
sixth month to the term of pregnancy. This is, however, a needless and 
confusing subdivision, which leads to no practical result. It suffices to 
apply the term abortion or miscarriage indiscriminately to all cases in 
which pregnancy is terminated before the foetus has arrived at a viable 
age, and premature labor to those in which there is a possibility of its 
survival. There is little or no hope of a foetus living before the 28th 
week or seventh lunar month, and this period is therefore generally fixed 
on as the limit between premature labor and abortion. The rule is, 
however, not without an occasional, although very rare, exception. Dr. 
Keiller of Edinburgh has recorded an instance in which a foetus was 
born alive at the fourth month, nine days after the mother had experi- 
enced the sensation of quickening. I myself recently attended a lady 
who miscarried in the fifth month of pregnancy, the child being born alive 
and living for three hours. Several cases are on record in which after 
delivery in the sixth month the child survived and was reared. The 
possibility of the birth of a living child under such circumstances should 
be recognized, as it may give rise to legal questions of importance ; but 
the exceptions to the ordinary rule are so rare that they need not interfere 
with the division of the subject usually made. 

Abortion is most Common in Multiparas — Multipara? abort far more 
frequently than primiparse. This is contrary to the statement in many 
obstetrical works. Thus, Tyler Smith says "there seems to be a greater 
danger of this accident in the first pregnancy." Schroeder, 1 however, 
states that 23 multiparas abort to 3 primiparse; and Dr. Whitehead of 
Manchester, who has particularly studied the subject, believes that abor- 
tion is more apt to occur after the third and fourth pregnancies, espe- 
cially when these take place toward the time for the cessation of men- 
struation. 

lAability to a Recurrent of Abortion. — There can be no doubt thai 
women who have aborted more than once are peculiarly liable to a 
recurrence of the accident. This can generally be traced to the exist- 
ence of some predisposing cause which persists through several pregnan- 
cies, as, for example, a syphilitic taint, a uterine flexion, or a morbid 
state of the lining membrane of the uterus. It is probable that in many 
women a recurrence of the accident induces a habit of abortion, or per- 
haps it might be more accurate to say a peculiar irritable condition of 
Schroeder, Manual of Midwifery, p. 149. 



244 ■ PBEGNANCY. 

the uterus, which renders the continuance of pregnancy a matter of diffi- 
culty, independently of any recognizable organic cause. 

Very Early Abortions are often Unrecognized. — The frequency of 
abortion varies much at different periods of pregnancy ; and it occurs 
much more often in the early months, because of the comparatively 
slight connection then existing between the chorion and the decidua. 
At a very early period of pregnancy the ovum is cast off with such facil- 
ity, and is of such minute size, that the fact of abortion having occurred 
passes unrecognized. Very many cases in which the patient goes one 
or two weeks over her time, and then has what is supposed to be merely 
a more than usually profuse period, are probably instances of such early 
miscarriages. Velpeau detected an ovum of about fourteen days which 
was not larger than an ordinary pea ; and it is easy to understand how 
so small a body should pass unnoticed in the blood which escapes along 
with it. 

Before the End of the Third Month the Ovum is generally Expelled 
Entire, — Up to the end of the third month, when miscarriage occurs, the 
ovum is generally cast oif en masse, the decidua subsequently coining 
away in shreds or as an entire membrane. The abortion is then com- 
paratively easy. From the third to the sixth month, after the placenta 
is formed, the amnion is, as a rule, first ruptured by the uterine contrac- 
tions, and the fetus is expelled by itself. The placenta and membranes 
may then be shed as in ordinary labor. It often happens, however, that 
on account of the firmness of the placental adhesion at this period the 
secunclines are retained for a greater or less length of time. This sub- 
jects the patient to many risks, especially to those of profuse hemor- 
rhage and of septicaemia. For this reason, premature termination of the 
pregnancy is attended by much greater danger to the mother between 
the third and sixth months than at an earlier or later date. After the 
sixth month the course of events is not different from that attending 
ordinary labor. The prognosis to the child is more unfavorable in pro- 
portion to the distance from the full period of gestation at which pre- 
mature labor takes place. 

Causes. — The causes of abortion may conveniently be subdivided into 
the predisposing and exciting, the latter being often slight, and such as 
would have no effect in inducing uterine contractions in women unless 
associated with one or more of the former class of causes. The predis- 
position to abortion may depend on some condition interfering with the 
vitality of the ovum or its relation to the maternal structures, or on cer- 
tain conditions directly affecting the mother's health. 

Causes Referable to the Foetus. — One of the most common antecedents 
of abortion is the death of the foetus, which leads to secondary changes, 
and ultimately produces the uterine contractions which end in its expul- 
sion. The precise causes of death in any given case cannot always be 
accurately ascertained, as they sometimes depend on conditions which 
are traceable to the maternal structures, at others to the ovular, or it 
may be to a combination of the two. Nor does it by any means follow 
that the death of the ovum immediately results in its expulsion. The 
mode in which death of the ovum produces abortion is not difficult to 
understand, for it necessarily leads to changes in the relations between 



ABORTION AXB PREMATURE LABOR. 



245 



the ovular and maternal structures ; these changes cause hemorrhages — 
partly external and partly into the membranes — which in their turn 
excite uterine contraction. Extravasations of blood may take place in 
various positions. One of the most common is into the decidual cavity, 
between the decidua vera and the decidua renexa, or between the decidua 
vera and the uterine walls. If the hemorrhage is only slight, and espe- 
cially if it comes from that portion of the decidua near the internal os 
and at a distance from the ovum, there need be no material separation, 
and pregnancy may continue. This explains the cases occasionally met 
with in which there is more or less hemorrhage without subsequent 
abortion. When the amount of extra vasated blood is at all great, sepa- 
ration and abortion necessarily result, and the decidua will be found on 
expulsion to have coagula on its surface and between its various layers 
which are found to project into the cavity of the amnion (Fig. 94). In 

Fig. 94. 




An Apoplectic Ovum, with Blood effused in masses under tin- Foetal Surface of the Membranes. 



other cases hemorrhage is still more extensive, and, alter breaking 
through the decidua reflexa, it forms clots between it and the chorion, 
and even in the cavity of the amnion. Supposing expulsion to take 
place shortly after coagula are deposited among the membranes, the 
blood is little altered, and we have an ordinary abortion. If, however, 
the ovum i- retained, the coagulated fibrin and the placenta or mem- 
branes undergo secondary changes which lead to the formation of moles. 
The so-called fleshy mole (Fig. 95) is often retained for many weeks or 
months after the death of the foetus, and during this time there maj be 
but little modification of the usual symptoms of pregnancy ; or, as is 
frequently the case, it gives rise to occasional hemorrhage, until ;it last 
uterine contractions come on, and it i- cast oil' in the form of a thick 
fleshy mass, having hut little resemblance to the ordinary products of 



246 



PREGNANCY. 



conception. The most probable explanation of its formation is, that 
when hemorrhage originally took place the effusion of blood was not 
sufficient to effect the entire separation and expulsion of the ovum. 
Part of the membranes or of the placenta — if that organ had commenced 
to form — retained its organic connection with the uterus, while the foetus 



Frs. 95. 




Blighted Ovum, with Fleshy Degeneration of the Membranes. 

perished. The attached portion of the placenta or membranes continues 
to be nourished, although abnormally. The foetus generally entirely 
disappears, especially if it has perished at an early period of utero-gesta- 
tion, when it becomes dissolved in the liquor amnii. Or it may become 
macerated, shrivelled, and greatly altered in appearance. The effused 
blood becomes decolorized from the absorption of the corpuscles, and, 
according to Scanzoni, fresh vessels are developed in the fibrin, which 
increase the vascular attachment of the mole to the uterine walls. The 
placenta and membranes may go on increasing in thickness until they 
form a mass of considerable size. Careful microscopic examination will 
almost* always enable us to discover the villi of the chorion, altered in 
appearance, often loaded w T ith granular fatty molecules, but sufficiently 
distinct to be readily recognizable. 

Causes depending on the Maternal State. — Important as are the causes 
of abortion arising from some morbid condition of the ovum, they are 
not more so than those which depend on the maternal state, and it is to 
be observed that the former are often indirect causes, produced by pri- 
mary maternal changes. Many of these maternal causes act by causing 
hypersemia of the uterus, which leads to extravasation of blood. Thus, 
abortion is apt to occur in women who lead unhealthy lives, such as 
those who occupy overheated and ill-ventilated rooms or indulge to 
excess in the fatigues and pleasures of society, in the use of alcoholic 
drinks, and the like. Over-frequent coitus has been, for the same rea- 
son, observed to produce a remarkable tendency to abortion, and Parent- 



ABORTION AXD PREMATURE LABOR. 247 

Duchatelet has noted that it is of very frequent occurrence amongst 
women of loose life. Many diseases strongly predispose to it, such as 
fevers, zymotic diseases of all kinds, measles, scarlet fever, small-pox ; 
and diseases of the respiratory organs, such as bronchitis and pneu- 
monia. Syphilis is well known to be one of the most frequent causes, 
and one that is likely to act in successive pregnancies. It may act so 
that the pregnancy is brought to a premature termination, time alter 
time, until the constitutional disease is eradicated by appropriate treat- 
ment. It acts in some cases through the influence of the father in pro- 
ducing a diseased ovum, and it is the only cause which can with certain tv 
be traced to the state of the father's health. Many other morbid condi- 
tions of the blood also dispose to abortion. It has been observed to be 
a frequent result of lead-poisoning ; also of the presence of noxious gases 
in the atmosphere, such as an excess of carbonic acid. 

Causes acting through the Nervous System. — Many causes act through 
the nervous system, such as fright, anxiety, sudden shock, and the like. 
Thus, there are numerous instances on record in which women aborted 
suddenly after the receipt of some bad news, and it is said to have been 
of frequent occurrence in women immediately before execution. The 
influence of irritation propagated through the nervous system from a 
distance, tending to produce uterine contraction and abortion through 
the agency of reflex action, has been specially dwelt upon by Tyler 
Smith. Thus he points out that abortion not unfrequently occurs from 
the irritation of constant suckling in women who become pregnant 
during lactation. The effect of suckling in producing uterine con- 
traction is indeed well known, and the application of the child to the 
breast for this purpose has long been recognized as a method of treat- 
ment in post-partum hemorrhage. The irritation of the trifacial in 
severe toothache, of the renal nerves in cases of gravel, in albuminuria, 
etc., of the intestinal nerves in excessive vomiting, in diarrhoea, obsti- 
nate constipation, ascarides, etc., all act in the same way. We may 
perhaps also explain by this hypothesis the fact that women are more 
apt to abort at what would have been the menstrual epoch than at other 
times, as the ovarian nerves may then be subject to undue excitement. 
It is probable, however, that there may be also at these times more or 
Less active congestion of the decidua, which may predispose to laceration 
of its capillaries and blood-extravasation. Such congestion exists in 
those exceptional cases in which menstruation continues for one or more 
period- after conception, the blood probably escaping from the -pace 
between the decidua vera and reflcxa ; and therefore there is no reason 
to question its also happening even when such abnormal menstruation is 
not present. 

Physical Causes. — Certain physical causes may produce abortion by 
separating the ovum. Thus it may follow a fall, ;i blow, or other 
accidents of a trivial character. On the other hand, women may !»<■ 
subjected to injuries of the severest kind without aborting. The prob- 
ability, therefore, is that these apparently trivial causes only operate in 
women who for some other reason are predisposed to the accident. This 
is borne out by the fact — which is well known in these days, when the 
artificial production of abortion is, unhappily, far from ;i verj rare 



248 PREGNANCY. 

event — that it is by no means easy to destroy the vitality of the foetus. 
I myself know of a case in which the uterine sound was passed several 
times into a pregnant uterus without producing abortion , the pregnancy 
proceeding to term. Oldham has related a similar case in which he in 
vain attempted to produce abortion by the sound in a case of contracted 
pelvis ; and Duncan has mentioned an instance in which an intra-uterine 
stem pessary was unwittingly introduced, and worn for some time by a 
pregnant woman, without any bad effect. The fact that pregnancy is 
with difficulty interfered with when there is a healthy relation between 
the ovum and the uterus no doubt explains the disastrous effects of 
criminal abortion which have been especially insisted on by many of our 
American brethren. 

Cases depending on Morbid States of the Uterus. — Morbid states of 
the uterus have an important influence in the production of abortion. 
Any condition which mechanically interferes with the proper develop- 
ment of the uterus is apt to operate in this way. Amongst these may 
be mentioned fibroid tumors ; the presence of old peritoneal adhesions, 
rendering the womb a more or less fixed organ ; but, above all, flexion 
and displacement of the uterus. Retroflexion of the uterus is unques- 
tionably one of the most frequent factors in its production, not only on 
account of the irritation which the abnormal position sets up, but from 
interference with the uterine circulation, which leads to the effusion of 
blood and the death of the ovum. An inflamed condition of the cervical 
and uterine mucous membranes will act in the same way should preg- 
nancy have occurred, although such a condition more often prevents 
conception taking place. 

Symptoms. — One of the earliest indications of impending abortion is 
more or less hemorrhage. This may at first be slight, and may last for 
a short time only, recurring after an interval of time, or it may com- 
mence with a sudden and profuse discharge. Occasionally it is very 
abundant, and its continuance and amount form one of the gravest 
symptoms of the accident. After the loss of blood has continued for 
a greater or less length of time — it may be even for some days — uterine 
contractions come on, recurring at regular intervals, and eventually lead 
to the expulsion of the ovum. More rarely the impending miscarriage 
commences with pains which lead to laceration of vessels and hemor- 
rhage. 

When Pain and Hemorrhage Coexist. — As long as one or other of 
these symptoms exist alone we may hope to avert the threatened mis- 
carriage, but when both occur together there is little or no chance of its 
being arrested. Certain premonitory symptoms are described by authors 
as common in abortion, such as feverishness, shivering, a sensation of 
coldness ; all of which are obscure and unreliable, and are certainly 
much more frequently absent than present. 

If the pregnancy be early, it is probable that the entire ovum will be 
shed with little trouble, and it often passes unperceived in the clots 
which surround it. It is therefore of importance that all the discharges 
should be very carefully examined. After the second month the rigid 
and undilated cervix presents a formidable obstacle to the escape of the 
ovum, and it may be a considerable time before there is sufficient dilata- 



ABOBTION ASD PREMATURE LABOR. 249 

tion to admit of its passage. This is gradually effected by the continu- 
ance of pains, but not without a severe loss of blood. It may be that the 
amnion is ruptured and the foetus expelled first. After a lapse of time 
the secundines are also shed, but there may be a considerable delay, 
amounting even to days, before this is effected. As long as any por- 
tions of the membranes are retained in utero the patient is necessarily 
subjected to considerable risk, not only from the continuance of hemor- 
rhage, but also from septicaemia. Hence it may be laid down as a rule 
that we can never consider our patient out of danger until we have sat- 
isfied ourselves that the whole of the uterine contents have been expelled. 

Treatment. — Our first endeavor in any case of impending miscarriage 
will be, of course, to avert the threatened accident. If hemorrhage has not 
been excessive, and if on vaginal examination — which should always be 
practised — we find no dilatation of the os, we may entertain a reasonable 
hope of success. If, on the contrary, we find the os beginning to open, 
if we are able to insert the finger through it so as to touch the ovum, 
especially if pains also exist, we are justified in considering abortion to 
be inevitable, and the indication will then be to have the ovum expelled 
and the case terminated as soon as possible. In the former case the 
most absolute rest is the first thing to insist on. The patient should be 
placed in bed, not overburdened with clothes, in a cool temperature, and 
she should have a light and easily-assimilated diet. All movements, 
even rising out of bed to empty the bladder or bowels, should be abso- 
lutely prohibited. To avert the tendency to the commencement of ute- 
rine contraction there is no remedy so useful as opium, which must be 
given freely and frequently repeated. It may be administered either in 
the form of laudanum or of Battley's sedative solution, which has the 
advantage of producing less general disturbance. It may be advantage- 
ously exhibited in doses of from 20 to 30 minims, and repeated after a 
few hours. A still better preparation is chlorodyne, which I have found 
of extreme value in arresting impending miscarriage, in doses of 10 
minims repeated every third or fourth hour. If, from any other cause, 
it is considered unadvisable to give the sedative by the mouth, it may be 
administered in a small starch enema per rectum. In all cases it will be 
necessary to keep the patient more or less under the influence of the drug 
for several days and until all symptoms of miscarriage have passed 
away. Care should be taken that the bowels do not become locked up 
by the action of the opiates — as this might of itself be a cause of irrita- 
tion — and their constipating effects ought to be obviated by small doses 
of castor oil or other gentle aperient. Various subsidiary methods of 
treatment have been recommended, such as bleeding from the arm or the 
local application of leeches in supposed plethoric -tales of the system ; 
revulsives, such as dry cupping to the loins; the application of ice, to 
check hemorrhage; astringents, such as acetate of lead or gallic acid, for 
the same purpose. Most of these, if not hurtful, will be at leasl use- 
less. The cases in which venesection would be beneficial are extremely 
rare, and the local applications, especially cold, are much more apt to 
favor than to prevent uterine action. 

Prophylactic Treatment. — In cases of repeated miscarriage in successive 
pregnancies a special course of prophylactic treatment is indicated, and 



250 PBEGNAXCY. 

is often attended with much success. In cases of this kind the first indi- 
cation, and one which ought to be carefully attended to, is to seek for 
and, if possible, to remove or mitigate the cause which has given rise to 
the former abortions. Those causes which depend on constitutional 
states must first be carefully investigated, and treated according to the 
indications present. These may be obscure and not easily discovered ; 
but it is certainly unwise to assume too readily the existence of what 
has been called " a habit of abortion," which further inquiry may prove 
to be only an indication of constitutional debility, degeneracy of the 
placental structures, or a latent and unsuspected syphilitic taint. If 
constitutional debility be present to a marked extent, a generous diet and 
a restorative course of treatment (preparations of iron, quinine, and 
other suitable tonics) may effect the desired object. 

[As an evidence of the efficiency of opium, I once succeeded in arrest- 
ing a labor at four and a half months by repeated doses of sulphate of 
morphia, in the case of a lady who was in a decidedly parturient state 
for ten hours, with recurrent uterine contractions, accompanied by pain 
and a considerable loss of blood. Under the narcotic the pains became 
more and more infrequent until they finally ceased, and the patient car- 
ried the foetus to the full period. It was a small female child, and lived 
some months, its delicacy being largely due to the fact that its mother 
was phthisical. In another case labor was arrested at eight months, and 
the foetus was carried to the full period. In the hands of some obstet- 
ricians the fluid extract of Viburnum prunifolmm would appear to act 
efficiently as a preventive of abortion in cases where the habit is known 
to. exist. In one case of this habit, after repeated failures, a residence 
in a mountainous region carried the patient through the usual period of 
danger, and the foetus is now a young lady. The mother was of very 
full habit, asthmatic, and at times rheumatic, but otherwise in excellent 
health. She usually aborted at six weeks. After three months she had 
occasional threatenings, but not any during the last two months. Rest 
in bed checked any apparent tendency to miscarry. — Ed.] 

Treatment in Cases depending on Local Causes. — Local congestion of 
the uterus or a general plethoric state of the patient has often been sup- 
posed to be an efficient cause of recurring abortion. Dr. Henry Bennet 
has especially dwelt on the influence of congestion and abrasions of the 
cervix in causing premature expulsion of the foetus, 1 and recommends 
the topical application of nitrate of silver or other caustics to the inflam- 
matory abrasions existing on the neck of the womb. Formerly vene- 
section was a favorite remedy ; and many authors have recommended 
the local abstraction of blood by leeches applied to the groin or round 
the anus, or even to the cervix. The influence of general plethora is 
more than doubtful ; and although local congestions are, probably, much 
more effective causes, still it would seem more judicious to treat them 
by rest and local sedatives rather than by topical applications, which, 
injudiciously applied, might produce the very accident they were in- 
tended to prevent. 

The position of the uterus should be carefully investigated. If it be 
found to be retroflexed, a well-fitting Hodge's pessary should be ap- 

1 On Inflammation of the Uterus, p. 432. 



ABORTION AND PREMATURE LABOR. 251 

plied, so as to support it until it has completely risen out of the 
pelvis. 

Treatment in Cases depending on Syphilis. — The possibility of syph- 
ilitic infection should always be . inquired into, for this poison may act 
on the product of conception long after all appreciable traces of it have 
disappeared from the infected parent. Should there be recurrent abor- 
tions in a patient who had formerly suffered from syphilis or whose 
husband had at any time contracted the disease, no time should be lost 
in using appropriate antisyphilitic remedies, which should invariably be 
administered both to the husband and wife. Diday especially insists 
that in such cases it is not sufficient to submit the father and mother to 
a mercurial course iii the absence of pregnancy, but that, as each suc- 
cessive impregnation occurs, the mother should again commence anti- 
syphilitic treatment, even though she has no visible traces of the disease. 1 
In this way there is reasonable ground for hoping that infection of the 
ovum may be prevented. I think, too, that we may be the more 
encouraged to persevere in the treatment of these unfortunate cases 
from the fact that the syphilitic poison tends to wear itself out. I 
have seen several cases in which this taint at first produced early abor- 
tion, then each successive pregnancy was of longer duration, until 
eventually a living child was born. 

In fatty degeneration of the chorion villi and in other morbid states of 
the placenta, which act by preventing the proper nutrition of the foetus 
and the due aeration of its blood, there is no reliable means of treat- 
ment except the general improvement of the mother's health. Simpson 
strongly recommended the administration of chlorate of potash in eases 
in which the child habitually dies in the latter months of pregnancy, on 
the supposition that it supplied to the blood a large amount of oxygen, 
and thus made up for any deficiency in the supply of that element 
through the placental tufts. The theory is at best a doubtful one, 
although I believe the drug to be unquestionably beneficial in cases of 
the kind.[ 2 ] It probably acts by its tonic properties rather than in the 
manner Simpson supposed. It may be given in doses of 15 to 20 
grains three times a day, and may be advantageously combined with 
small doses of dilute hydrochloric acid. In frequently-recurring pre- 
mature labors with dead children Simpson strongly recommended the 
induction of premature labor a little before the time at which we had 
reason to believe that the foetus lias usually peri hed ; or, in other 
words, before the placental disease had advanced sufficiently far t<> 
interfere with its nutrition. The practice has constantly been adopted 
with success, and is perfectly legitimate, but the difficulty, of course, is 
to fix on the right time. Careful auscultation of the foetal heart may 
be of some use in guiding us to a decision, as the death of the foetus is 
generally preceded for some days by irregular, tumultuous, and intermit- 
tent action of the heart. 

Treatment where no Cause ran be Discovered. — There will always 
remain a certain number of cases in which no appreciable cause can be 

1 Diday. Infantile Syphilis, Syd. Soc. Trans., i>. 207. 

[ 2 Chlorate of potash will not part with its oxygen except al a red heat. In the bvb- 
tera it remains unchanged, as proved by Prof. Leeds of Hoboken. — Ed.] 



252 PREGNANCY. 

discovered. Under such circumstances prolonged rest, at least until the 
time has passed at which abortion formerly took place, will afford the 
best chance of avoiding a recurrence of the accident. There must 
always be some difficulty in carrying out this indication, inasmuch as 
the patient's health is apt to suffer in other ways from the confinement 
and the want of fresh air and exercise which it entails. The strictness 
with which rest should be insisted on must vary in different cases, but 
it should be specially attended to at what would have been the men- 
strual periods. At these times the patient should remain in bed alto- 
gether ; at others she may lie on a sofa, and, if circumstances permit, 
spend part of the day at least in the open air. Sexual intercourse 
should be prohibited. Should actual symptoms of abortion come on, 
the preventive treatment, already indicated, may be resorted to. Great 
care, however, should be used in prescribing opiates as preventives, and 
they should be given for a specified time only. I have seen, more than 
once, an incurable habit of opium-eating originate from the incautious 
and too long-continued exhibition of the drug in such cases. 

When we have satisfied ourselves that abortion is inevitable, we must 
proceed to employ treatment that favors the expulsion of the ovum. 

Removal of the Ovum when within Reach. — If the os be sufficiently 
dilated and the pains strong, we may find the ovum separated and pro- 
truding from the os. We may then be able to detach it by the finger. 
For this purpose the uterus is depressed from without by the left hand, 
while an endeavor is made to scoop out the ovum with the examining 
finger. If it be out of reach, and yet appears detached, chloroform 
should be administered, the whole hand introduced into the vagina, and 
the finger into the uterine cavity. The complete detachment of the 
ovum can in this way be far more readily and safely effected than by 
using any of the many ovum-forceps which have been invented for the 
purpose. 

Plugging of the Vagina. — If the ovum be not sufficiently separated 
or the os be undilated, means must be taken to control the hemorrhage 
until the former can be removed or expelled. It is here that plugging 
of the vagina finds its most useful application. This may be done in 
various ways. That most usually employed is filling the vagina with a 
tolerably large sponge, in the interstices of which the blood coagulates. 
A better plan is to soak a number of pledgets of cotton wool in carbol- 
ized water and tie a string round each. The vagina can be completely 
and effectively packed with these, and this is best done through a specu- 
lum. Each pledget should be covered with glycerin, which completely 
prevents the offensive odor which otherwise always arises. The pledgets 
can be removed by traction on the strings, but if these are not used much 
pain is caused in getting them out of the vagina. Th£ plug should 
never be left in for more than six or eight hours, after which a fresh one 
may be inserted if necessary. Two or three full doses of the liquid 
extract of ergot, of fess to f&j each, or a subcutaneous injection of ergo- 
tin, may be given while the plug is in position. The plug itself is a 
strong excitant of uterine action, and the two combined often effect com- 
plete detachment, so that on the removal of the tampon the ovum may 
be found lying loose in the os uteri. If the os be undilated and the 



ABORTION AND PREMATURE LABOR. 253 

ovum entirely out of reach, the former may be opened by means of sponge 
or laminaria tents. I think a well-prepared sponge tent the most effectual, 
and it can be maintained in situ by a vaginal plug below it. It also acts 
as a most efficient plug, effectually controlling all hemorrhage. In a 
few hours it opens up the os sufficiently to admit the finger. 

Retention of the Membranes. — The most troublesome cases are those in 
which the foetus is first expelled and the placenta and membranes remain 
in utero. As long as this is the case the patient can never be con- 
sidered safe from the occurrence of septicemia. Dr. Priestley has 
strongly insisted on the importance of removing the secundines as soon 
-as possible. There can be no doubt that this should be done whenever 
it is feasible. Cases, however, are frequently met with in which any 
forcible attempt at removal would be likely to prove very hurtful, and 
in which it is better practice to control hemorrhage by the plug or sponge 
tent, and wait until the placenta is detached, which it will generally be 
in a day or two at most. Under such circumstances fetor and decompo- 
sition of the secundines may be prevented by intra-uterine injections of 
diluted Condy's fluid. Provided the os be sufficiently patulous to pre- 
vent the collection of the fluid in the uterine cavity, and not more than 
a drachm or two of fluid be injected at a time, so as simply to wash 
away and disinfect decomposing detritus, they can be used with perfect 
safety. Sometimes cases are met with in which the os has entirely closed, 
and in which we can only suspect the retention of the placenta by the 
history of the case, the continuance of hemorrhage, or the presence of a 
fetid discharge. Should we see reason to suspect this, the os must be 
dilated with sponge or laminaria tents and the uterine cavity thoroughly 
explored under chloroform. This condition of things is far from uncom- 
mon in women who have not had medical assistance from the first, and 
it often gives rise to very troublesome and anxious symptoms. It has 
been said that placentae thus retained have been completely absorbed, 
and cases of the kind have been related by Naegele and Osiander. The 
spontaneous absorption, however, of so highly organized a body as the 
placenta would be a phenomenon of the most remarkable character ; and 
it seems more natural to suppose that in most eases of the kind the pla- 
centa has been east off without the knowledge of the patient. Some- 
times the placenta never entirely becomes detached, and, retaining organic 
conned ion with the uterine walls, forms what has been culled a "placen- 
tal polypus." This may produce secondary hemorrhages, in the same 
way as an ordinary fibroid polypus. Barnes recommends the removal 
■of these masses by means of the wire ecraseur. Before their detection 
the os uteri must be opened up. 

Retention in Utero of a Blighted Oram. — The case- previously alluded 
to, in which an ovum has perished in early pregnancy and is retained in 
utero, are often puzzling, and may give rise to serious moral and medico- 
legal questions. The blighted ovum may be retained for many months, 
the outside limit, according to McClintock, 1 by whom the subject lias 
been ably discussed, being nine months. The appearance of the ovum 
when thrown off will give no reliable elue to the length of linn which 
has elapsed since it perished. The symptoms are often very obscure. 

'Sydenham's Society's ed. of SmeUitfa Midwifery^ vol. i. j>. 109. 



254 PREGNANCY. 

Generally there have been the usual indications of pregnancy, which, with 
or without signs of impending miscarriage, disappear or are modified, and 
then follows a period of ill-health, with pelvic uneasiness and irregular 
metrorrhagia, which may be mistaken for menstruation. Occasionally, 
but by no means necessarily, there is a fetid discharge, and this probably 
exists only when the membranes have broken and air has access to the 
ovum. In some cases obscure septicemic symptoms have been observed. 
Such symptoms are obviously too indefinite to lead to an accurate diag- 
nosis. In the course of 'time the ovum is generally thrown off, with 
more or less hemorrhage. If the nature of the case is detected, ergot 
may be given to promote the expulsion of the uterine contents, and it 
may even be advisable to dilate the cervix with sponge or laminaria 
tents and remove them artificially. 

Subsequent Management. — The frequency with which abortion leads 
to chronic uterine disease should lead us to attach much more importance 
to the subsequent management of the patient than has been customary. 
The usual practice is to confine the patient to bed for two or three days 
only, and then to allow her to resume her ordinary avocations, on the 
supposition that a miscarriage requires less subsequent care than a con- 
finement. The contrary of this is, however, most probably the case, for 
the uterus has been emptied when it is unprepared for involution, and 
that process is often very imperfectly performed. We should therefore 
insist on at least as much attention being paid to rest as after labor at 
term. [A common cause of uterine hyperplasia is the imperfect invo- 
lution which is apt to follow an abortion at an early period of gestation, 
especially when the patient is not properly treated by rest in a recumbent 
position. Displacements of the uterus are apt to be produced by the 
erect position and exercise while the organ is heavy and its ligaments 
relaxed. — Ed.] 



PART III 

LAB OR. 



CHAPTER I. 

THE PHENOMENA OF LABOR. 

Delivery at Term. — In considering delivery at term we have to discuss 
two distinct classes of events. 

One of these is the series of vital actions brought into play in order to 
effect the expulsion of the child ; and the other consists of the move- 
ments imparted to the child, the body to be expelled — in other words, 
the mechanism of delivery. 

Causes of Labor. — Before proceeding to the consideration of these 
important topics a few words may be said as to the determining causes 
of labor. This subject has been from the earliest times a qucestio vexata 
among physiologists, and many and various are the theories which have 
been broached to explain the curious fact that labor spontaneously com- 
mences, if not at a fixed epoch, at any rate approximately so. It must 
be admitted that even yet there is no explanation which can be implicitly 
accepted. 

Foetal or Maternal Causes. — The explanations which have been given 
may be divided into two classes — those which attribute the advent of labor 
to the fcetus, and those which refer it to some change connected with the 
maternal generative organs. 

The former is the opinion which was held by the older accoucheurs, 
who assigned to the foetus some active influence in effecting its own 
expulsion. It need hardly be said that such fanciful views have no 
kind of physiological basis. Others have supposed that there might be 
some change in the placental circulation or in the vascular system of the 
foetus which might solve the mystery. The latest hypothesis of this 
kind — which, however, is not fortified by any evidena — is by Barnes, 
who says: "I rather incline to the opinion that when the foetus has 
attained its full development, when its organs are prepared for external 
life, some change takes place in its circulation which involves a correla- 
tive disturbance in the maternal circulation, which excites the attempt at 
labor." 1 

The majority of obstetricians, however, refer the advent of labor t«> 
purely maternal causes. Among the mure favorite theories is one which 
1 Diseases of Women, p. 434. 

255 



256 LABOR. 

was originally started in this country by Dr. Power and adopted and 
illustrated by Depaul, Dubois, and other writers. It is based on the 
assumption that there is a sphincter action of the fibres of the cervix 
analogous to that of the sphincters of the bladder and rectum, and that 
when the cervix is taken up into the general uterine cavity as pregnancy 
advances, the ovum presses upon it, irritates its nerves, and so sets up 
reflex action, which ends in the establishment of uterine contraction. 
This theory was founded on erroneous conceptions of the changes that 
occurred in the neck of the uterus ; and, as it is certain that obliteration 
of the cervix does not really take place in the manner that Power 
believed when his theory was broached, it is obvious that its supposed 
result cannot follow. 

Distension of the Uterus. — Extreme distension of the uterus has been 
held to be the determining cause of labor — a view lately revived by Dr. 
King of Washington, 1 who believes that contractions are induced 
because the uterus ceases to augment in capacity, while its contents still 
continue to increase. This hypothesis is sufficiently disproved by a 
number of clinical facts which show that the uterus may be subject to 
excessive and even rapid distension — as in cases of hydramnios, multiple 
pregnancy, and hydatidiform degeneration of the ovum — without the 
supervention of uterine contractions. 

Fcdty Degeneration of the Decidua. — Another inciter of uterine action 
has been supposed to be the separation of the ovum from its connections 
to the uterine parietes in consequence of fatty degeneration of the decidua 
occurring at the end of pregnancy. The supposed result of this change, 
which undoubtedly occurs, is that the ovum becomes so detached from 
its organic adhesions as to be somewhat in the position of a foreign body, 
and thus incites the nerves so largely distributed over the interior of the 
uterus. This theory, which has been widely accepted, was originally 
started by Sir James Simpson, who pointed out that some of the most 
efficient means of inducing labor (such, for example, as the insertion of 
a gum-elastic catheter between the ovum and the uterine walls) probably 
act in the same way — viz. by effective separation of the membranes and 
detachment of the ovum. 

Barnes instances, in opposition to this idea, the fact that ineffectual 
attempts at labor come on at the natural term of gestation in cases of 
extra-uterine pregnancy, when the foetus is altogether independent of 
the uterus, and therefore, he argues, the cause cannot be situated in the 
uterus itself. A fair answer to this argument would be that although, 
in such cases, the womb does not contain the ovum, it does contain a 
decidua, the degeneration and separation of which might suffice to 
induce the abortive and partial attempts at labor then witnessed. 

Objections to these Theories. — A serious objection to all these theories, 
which are based on the assumption that some local irritation brings on 
contraction, is the fact, which has not been generally appreciated, that 
uterine contractions are always present during pregnancy as a normal 
occurrence, and that they may be, and often are, readily intensified at 
any time, so as to result in premature delivery. 

It is, indeed, most likely that, at or about the full term, the nervous 

1 American Journal of Obstetrics, vol. iii. 



THE PHENOMENA OF LABOR. 257 

supply of the uterus is so highly developed, and in so advanced a state 
of irritability, that it more readily responds to stimuli than at other 
times. If by separation of the decidua, or in some other way, stimula- 
tion of the excitor nerves is then effected, more frequent and forcible 
contractions than usual may result, and, as they become stronger and 
more regular, terminate in labor. But, allowing this, it still remains 
quite unexplained why this should occur with such regularity at a def- 
inite time. 

Tyler Smith's Ovarian Theory. — Tyler Smith tried, indeed, to prove 
that labor came on naturally at what would have been a menstrual 
epoch, the congestion attending the menstrual nisus acting as the exciter 
of uterine contraction. He therefore refers the onset of labor to ovarian 
rather than to uterine causes. Although this view is upheld with all its 
author's great talent, there are several objections to it difficult to over- 
come. Thus, it assumes that the periodic changes in the ovary continue 
during pregnancy, of which there is no proof. Indeed, there is good rea- 
son to believe that ovulation is suspended during gestation, and with it, 
of course, the menstrual nisus. Besides, as has been well objected by 
Cazeaux, even if this theory were admitted, it would still leave the mys- 
tery unsolved, for it would not explain why the menstrual nisus should 
act in this way at the tenth menstrual epoch rather than at the ninth or 
eleventh. 

In spite, then, of many theories at our disposal, it is to be feared that 
we must admit ourselves to be still in entire ignorance of the reason 
why labor should come on at a fixed epoch. 

Mode in whieh the Expulsion of the Child is Effected. — The expulsion 
of the child is effected by the contractions of the muscular fibres of the 
uterus, aided by those of some of the abdominal muscles. These efforts 
are in the main entirely independent of volition. So far as regards the 
uterine contractions, this is absolutely true, for the mother has no power 
of originating, lessening, or increasing the action of the uterus. As 
regards the abdominal muscles, however, the mother is certainly able to 
bring them into action and to increase their power by voluntary efforts ; 
but, as labor advances and as the head passes into the vagina and irri- 
tates the nerves supplying it, the abdominal muscles are often stimulated 
to contract, through the influence of reflex action, independently of voli- 
tion on the part of the mother. 

The Chief Factor in Expulsion. — There can be little doubt that the 
chief agent in the expulsion of the child is the contraction of the uterus 
itself. This opinion is almost unanimously held by accoucheurs, and 
the influence of the abdominal muscles is believed to be purely accessory. 
Dr. Ilaughton, however, maintains a view which is directly contrary to 
this. From an examination of the force of the uterine contractions, 
arrived at by measuring the amount of muscular fibre contained in the 
wiills of the uterus, he arrive- at the conclusion thai the uterine contrac- 
tion- are chiefly influential in rupturing the membranes and dilating the 
OS uteri, bringing into action, if needful, a force equivalent to 54 lbs. ; 
but when this is effected, and the second stage of labor ha- commenced, 
he thinks the remainder of the labor is mainly completed by the coin fac- 
tions of the abdominal muscles, to which he attributes enormous powers 

17 



258 LABOR. 

— equivalent, if needful, to a pressure of 523.65 lbs. on the area of the 
pelvic canal. 

These views bear on a topic of primary consequence in the physiology 
of labor. They have been fully criticised by Duncan, who has devoted 
much experimental research to the study of the powers brought into 
action in the expulsion of the child. His conclusions are that, so far 
from the enormous force being employed that Haughton estimated, in 
the large majority of cases the effective force brought to bear on the 
child by the combined action of both the uterine and abdominal muscles 
is less than 50 lbs. ; that is, less than the force which Haughton attrib- 
uted to the uterus alone. In extremely severe labors, when the resist- 
ance is excessive, he thinks that extra power may be employed, but he 
estimates the maximum as not above 80 lbs., including in this total the 
action of both the uterine and abdominal muscles. Joulin arrived at the 
conclusion that the uterine contractions were capable of resisting a max- 
imum force of about one hundredweight. Both these estimates, it will 
be observed, are much under that of Haughton, which Duncan describes 
as representing " a strain to which the maternal machinery could not be 
subjected without instantaneous and utter destruction." 

Reasons on which this Conclusion is Based. — There are many facts in 
the history of parturition which make it certain that the chief factor in 
the expulsion of the child is the uterus. Among these may be men- 
tioned occasional cases in which the action of the abdominal muscles is 
materially lessened, if not annulled — as in profound anaesthesia and in 
some cases of paraplegia — in which, nevertheless, uterine contractions 
suffice to effect delivery. The most familiar example of its influence, 
however, and one that is a matter of every-day observation in practice, 
is when inertia of the uterus exists. In such cases no effort on the part 
of the mother, no amount of voluntary action that she can bring to bear 
on the child, has any appreciable, influence on the progress of the labor, 
which remains in abeyance until the defective uterine action is re-estab- 
lished or until artificial aid is given. 

The contraction of the uterus, then, being the main agent in delivery, 
it is important for us to appreciate its mode of action and its effect on 
the ovum. 

Uterine Contractions at the Commencement of Labor. — We have seen 
that intermittent and generally painless uterine contractions exist during 
pregnancy. As the period for delivery approaches these become more 
frequent and intense, until labor actually commences, when they begin 
to be sufficiently developed to effect the opening up of the os uteri with 
a view to the passage of the child. They are now accompanied by pain, 
which increases as labor advances, and is so characteristic that " pains " 
are universally used as a descriptive term for the contractions themselves. 
It does not necessarily follow that uterine contractions are painless until 
they commence to effect dilatation of the os uteri. On the contrary, 
during the last clays or even weeks of pregnancy women constantly have 
irregular contractions, accompanied by severe suffering, which, however, 
pass off without producing any marked effect on the cervix. When 
labor has actually begun, if the hand is placed on the uterus when a 
pain commences the contraction of its muscular tissue is very apparent, 



THE PHENOMENA OF LABOR. 259 

and the whole organ is observed to become tense and hard, the rigidity 
increasing until the pain has reached its acme, the uterine walls then 
relaxing and remaining soft until the next pain comes on. At the com- 
mencement of labor these pains are few, separated from each other by a 
considerable interval, and of short duration. In a perfectly typical 
labor the interval between the pains becomes shorter and shorter, while, 
at the same time, the duration of each pain is increased. At first they 
may occur only once in an hour or more, while eventually there may not 
be more than a few minutes' interval between them. 

Mode in which Dilatation of the Cervix is Effected. — If, when the pains 
are fairly established, a vaginal examination be made, the os uteri will 
be found to be thinned and dilated in proportion to the progress of the 
labor. During the contraction the bag of membranes will be felt to 
bulge, to become tense from the downward pressure of the liquor amnii 
within it, and to protrude through the os if it be sufficiently open. The 
membranes, with the contained liquor amnii, thus form a fluid wedge, 
which has a most important influence in dilating the os uteri (see Front- 
ispiece). This does not, however, form the sole mechanism by which 
the os uteri is dilated, for it is also acted upon by the contractions of 
the muscular fibres of the uterus, which tend to pull it open. It is 
probable that the muscular dilatation of the os is effected chiefly by the 
longitudinal fibres, which, as they shorten, act upon the os uteri, the 
part where there is least resistance. 

Partly, then, by muscular contraction, partly by mechanical pressure, 
the cervical canal is dilated, and as it opens up it becomes thinner and 
thinner, until it is entirely taken up into the uterine cavity. 

Rupture of the Membranes. — There is no longer any obstacle to the 
passage of the presenting part of the child into the cavity of the pelvis, 
and the force of the pains now generally effects the rupture of the mem- 
branes and the escape of the liquor amnii. There is often observed, at 
tins time, a temporary relaxation in the frequency of the pains, which 
had been steadily increasing ; but they soon recommence with increased 
vigor. If the abdomen be now examined, it will be observed to be 
much diminished in size, partly in consequence of the escape of the 
liquor amnii, partly from the descent of the fetus into the pelvic cavity. 

Change in the Character of the Pains. — The character of the pains 
soon changes. They become stronger, longer in duration, separated by a 
shorter interval, and accompanied by a distinct forcing effort, being ll<h- 
erally described as "the bearing-down" pains. Now is the time at 
which the accessory muscles of parturition come into operation. The 
patient brings them into play in the manner which will be subsequently 
described, and the combined action of the uterine and abdominal mu- 
ch- continues until the expulsion of the child is effected. 

Mode qf Action of the Uterus. — The precise mode of uterine contrac- 
tion is still somewhat a matter of dispute. It is generally described as 
commencing in the cervix, passing gradually upward by peristaltic 
action, the wave then returning downward toward the OS uteri. This 
view was maintained by Wigand, and ha- been endorsed by Rigby, 
Tyler Smith, and many other writers. In support of it they instance 
the fact that on the accession of a pain the presenting part first recedes : 



260 LABOR. 

the bag of membranes then becomes tense and protrudes through the os, 
and it is not until some time that the presenting part of the child itself 
is pushed down. It is very doubtful if this view is correct ; and a care- 
ful examination of the course of the pains would rather lead to the 
belief that the contractions commence at the fundus, where the muscular 
tissue is most largely developed, and gradually proceed downward to the 
cervix, the waves of contraction being, however, so rapid that the whole 
organ seems to harden en masse. The apparent recession of the present- 
ing part and the bulging of the bag of membranes are certainly no proof 
that the contractions begin at the cervix ; for the commencing contraction 
would necessarily push down the fluid in front of the head, and cause 
the membranes to bulge and the os to become tense before its force was 
brought to bear on the foetus itself. Indeed, did the contraction com- 
mence at the lower part of the uterus, we should expect the opposite of 
what takes place to occur, and the waters to be pushed upward and 
away from the cervix. The fundal origin of the contraction is further 
illustrated by what is observed when the hand of the accoucheur is 
placed in the uterine cavity, as often happens in certain cases of hem- 
orrhage or turning ; for if a pain then comes on, it will be felt to 
start at the fundus, and gradually compress the hand from above 
downward. 

Value of the Intermittent Character of the Pains. — The intermittent 
character of the contractions is of great practical importance. Were 
they continuous, not only would the muscular powers of the patient be 
rapidly exhausted, but by the obliteration of the vessels produced by the 
muscular contraction the circulation through the placenta would be inter- 
fered with and the life of the child imperilled. Hence, one of the chief 
dangers of protracted labor, especially after the escape of the liquor 
amnii, is that the uterine fibres may enter into a state of tonic rigidity 
— a condition that cannot be long continued without serious risks both 
to the mother and child. 

The Contractions are Incited through the Sympathetic Nerves. — The 
fact that the uterine contractions are altogether involuntary proves them 
to be excited — as indeed we would a priori infer from our knowledge 
of the anatomical arrangement of the nerves of the uterus — solely by 
the sympathetic system. Still, it is a fact of every-day observation that 
they can be largely influenced by emotions. Various stimuli applied to 
the spinal system of nerves (as, for example, when the mammse are irri- 
tated) have also a marked effect in inducing uterine contraction. The 
precise mode in which such influence is conveyed to the uterus, in spite 
of the numerous experiments which have been made for the purpose of 
determining how far labor is affected by destruction of the spinal cord, 
is still a matter of doubt. After the foetus has passed through the cer- 
vix the spinal nerves distributed to the vagina and perineum are excited 
by the pressure of the presenting part, and through them the accessory 
powers of parturition are chiefly brought into play. The contraction of 
the muscles of the vagina itself is supposed to have some influence in fav- 
oring the expulsion of the foetus after the birth of part of the body, and 
also in promoting the expulsion of the placenta. In the lower animals the 
vagina has a very marked contractile property, and is, in some of them, 



THE PHENOMENA OF LABOR. 261 

the main agent by which the young are expelled. In the human subject 
this influence is certainly of very secondary importance. 

Character and Source of Pains during Labor. — The amount of suf- 
fering experienced during labor varies much in different cases, and is in 
direct proportion to the nervous susceptibility of the patient. There are 
some women who go through labor with little or no pain at all. This 
is proved by the cases (of which there are numerous authentic instances 
recorded) in which labor has commenced during sleep, and the child has 
been actually born without the mother awaking. I am acquainted with 
a lady who has had a large family, who assures me that, though labor 
is accompanied by a sense of pressure and discomfort, she experiences 
nothing which can be called actual pain. Such a happy state of affairs 
is, however, extremely exceptional, and in the vast majority of cases par- 
turition is accompanied by intense suffering during its whole course, in 
some cases amounting to anguish which has probably no parallel under 
any other condition. 

The precise cause of the pain has been much discussed, and is no 
doubt complex. 

In the First Stage. — In the early stage of labor, and before the dilata- 
tion of the os, it is chiefly seated in the back, from whence it shoots 
round the loins and down the thighs. It is then probably produced 
partly by pressure on the nerve-filaments, caused by contraction of the 
muscular fibres to which they are distributed, and partly by stretching 
and dilatation of the muscular tissue of the cervix. M. Beau believes 
that in this stage the pain is not produced, strictly speaking, in the ute- 
rus itself, but is rather a neuralgia of the lumbo-abdominal nerves. The 
pains at this time are generally described as " acute" and "grinding" 
— terms which sufficiently well express their nature. In highly-nervous 
women these pains are often much less well borne than those of a later 
stage, and the suffering they undergo is indicated by their extreme rest- 
lessness and loud cries as each contraction supervenes. As the os dilates 
and the labor advances into the expulsive stage other sources of suffer- 
ing are added. : 

In the Second Stage. — The presenting part now passes into the vagina 
and presses on the vaginal nerves, as well as on the large nervous plex- 
uses lying in the pelvis. As it descends lower it stretches the perineum 
and vulva and presses on the bladder and rectum. Hence cramps are 
produced in the muscles supplied by the nerve-plexuses, as well as an 
intolerable sense of tearing and stretching in the vulva and perineum, 
and often a distressing feeling of tenesmus in the bowels. By this time 
the accessory muscles of parturition are brought Into action, and they, 
as well as the uterine muscle-, are thrown into frequenl and violent con- 
tractions, which, independently of the other cause- mentioned, are suffi- 
cient of themselves to produce great pain, likened to that of colic pro- 
duced by involuntary and repeated contraction of the muscles of the 
intestines. 

Taking all these cause- into consideration, there is no lack of suffi- 
cient explanation of the intolerable suffering which is so constant an 
accompaniment of childbirth. 

Effect of the Pains on the Mother and Foetus. — The effed of the pain- 



262 LABOR. 

on the mother's circulation is well marked. The rapidity of the pulse 
increases distinctly with each contraction, and as the pain passes off it again 
declines to its former state. A similar observation has been made with 
regard to the sounds of the foetal heart, especially after the expulsion of 
the liquor amnii. Hicks has pointed out that during a pain the mus- 
cular vibrations give rise to a sound which often resembles that of the 
foetal heart, and which completely disappears when the muscular tissue 
relaxes. The effect of the pain in intensifying the uterine souffle has 
been already mentioned. The strong muscular efforts Avould naturally 
lead us to expect a marked elevation of temperature during labor. Fur- 
ther observations on this point are required, but Squire asserts that there 
is generally only a very slight increase in temperature during delivery, 
rapidly passing off as soon as labor is over. 

Division of Labor into Stages. — Such being the physiological facts in 
connection with the labor-pains, we may now describe the ordinary prog- 
ress of a natural labor — that is, one terminated by the natural poAvers 
and with a head presenting. 

For facility of description obstetricians have long been in the habit 
of dividing the course of labor into stages, which correspond pretty 
accurately with the natural sequence of events. For this purpose Ave 
generally talk of three stages — viz. : 1, from the commencement of regu- 
lar pains until the complete dilatation of the ceiwix ; 2, from the com- 
plete dilatation of the ceiwix until the expulsion of the child ; 3, the 
concluding stage, comprising the permanent contraction of the uterus 
and the separation and expulsion of the placenta. To these Ave may con- 
A T eniently add a preparatory stage, antecedent to the regular commence- 
ment of the labor. 

Preparatory Stage. — For a short time before cleliA T ery, varying from 
a few days to a week or two, certain premonitory symptoms generally 
exist Avhich indicate the approaching advent of labor. Sometimes they 
are Avell marked, and cannot be mistaken ; at others they are so slight 
as to escape observation. Amongst the most common is a sinking of 
the uterus into the pelvic cavity, resulting from the relaxation of the 
soft parts preceding delivery. The result is, that the upper edge of the 
uterine tumor is less high than before, and, in consequence, the pressure 
on the respiratory organs is diminished, and the woman often feels lighter, 
and altogether less unwieldy, than in the previous weeks. If a vaginal 
examination be made at this time, the loAver segment of the uterus will 
be found to haA T e sunk lower into the pelvic cavity ; and the consequence 
of this is that, while the respiration is less embarrassed and the patient 
feels less bulky, other accompaniments of pregnancy, such as hemor- 
rhoids, irritability of the bladder and bowels, and oedema of the limbs, 
become aggra\ T ated. The increased pressure on the bowels often induces 
a sort of temporary diarrhoea, which is so far advantageous that it emp- 
ties the bowels of feces which may have collected within them. As has 
already been pointed out, the contractions which have been going on at 
intervals during the latter months of pregnancy now get more and more 
marked, and they have the effect of producing a real shortening of the 
cervix, which is of great value preparatory to its dilatation. More 
marked mucous discharge from the cavity of the cervix also generally 



THE PHENOMENA OF LABOR. 263 

occurs a short time before labor, and it is not unfrequently tinged with 
blood from the laceration of minute capillary vessels. This discharge, 
popularly known as the "shows" is a pretty sure sign that labor is not 
far off. It may, however, be entirely absent, even until the birth of the 
child. When copious it serves to lubricate the passages, and is generally 
coincident with rapid dilatation of the parts and a speedy labor. 

False Pains. — During this time (premonitory stage) painful uterine 
contractions are often present, which, however, have no effect in dilating 
the cervix. In some cases they are frequent and severe, and are very 
apt to be mistaken for the commencement of real labor. Such "false 
pains," as they are termed, are often excited and kept up by local irrita- 
tions, such as a loaded or disordered state of the intestinal canal ; and 
they frequently give rise to considerable distress and much inconvenience 
both to the patient and practitioner. They are, it should be remembered, 
only the normal contractions of the uterus, intensified and accompanied 
with pain. 

First Stage, or Dilatation. — As labor actually commences the uterine 
contractions become stronger, and the fact that they are "true" pains 
can be ascertained by their effect on the cervix. If a vaginal examina- 
tion be made during one of these, the membranes will be felt to become 
tense and bulging during the pain, and the os uteri will be found par- 
tially dilated and thinned at its edges. As labor advances this effect on 
the os becomes more and more marked. At first the dilatation is very 
slight, perhaps not more than enough to admit the tip of the examining 
finger, and both the upper and lower orifices of the cervix can he made 
out. As the pains get stronger and more frequent, dilatation proceeds 
in the way already described, and the cervix gets more thin and tense, 
until we can feel a thin circular ring (which is lax between the pains, 
but becomes rigid and tense during the contraction, when the bag of 
waters bulges through it), without any distinction between the upper and 
lower orifices. During this time the patient, although she may be suffer- 
ing acutely, is generally able to sit up and walk about. The amount of 
pain experienced varies much according to the character of the patient. In 
emotional women of highly-developed nervous susceptibilities it is gener- 
ally very great. They are restless, irritable, and desponding, and when the 
pain comes on cry out loudly. The character of the cry is peculiar and 
well marked during the first stage, and has constantly been described by 
obstetric writers as characteristic. It is acute and high, and is certainly 
very different from the deep groans of the second stage, when the breath 
is involuntarily retained to assist the parturient effort. When dilatation 
is nearly completed various reflex nervous phenomena often show them- 
selves. One of these is nausea and vomiting ; another is uncontrollable 
shivering, which is not accompanied by a sense of coldness, the patient 

being often hot and perspiring. Both these symptom- indicate thai the 
propulsive stage will shortly commence, and they may be regarded as 
favorable rather than otherwise, although they are apt to alarm the 
patient and her friends. By this time the <>- is fully dilated, the mem- 
branes generally rupture spontaneously, and a considerable portion of 
the liquor amnii Hows away. The head, if presenting, often acts as a 
sort of ball-valve, and, falling down on the aperture of the cervix, pre- 



264 LABOR. 

vents the complete evacuation of the liquor amnii, which escapes by 
degrees during the rest of the labor or may be retained in considerable 
quantity until the birth of the child. 

It not unfrequently happens, if the membranes are somewhat tougher 
than usual and the pains frequent and strong, that the foetus is pushed 
through the pelvis, and even expelled, surrounded by the membranes. 
When this occurs the child is said to be. born with a " caul ;" and this 
event would doubtless happen more frequently than it does were it not 
the custom of the accoucheur to rupture the membranes artificially as 
soon as the os is completely opened up, after which time their integrity 
is no longer of any value. 

Second Stage, or Propulsion. — The os is now entirely retracted over 
the presenting part, and is no longer to be felt, the vagina and the ute- 
rine cavity forming a single canal. Now the mucous discharge is gener- 
ally abundant, so that the examining finger brings away long strings of 
glairy, transparent mucus, tinged with blood. The pains, after a short 
interval of rest, become entirely altered in character. The uterus con- 
tracts tightly round the foetus, the presenting part descends into the pel- 
vis, and the true propulsive pains commence. The accessory muscles of 
parturition now come into play. With each pain the patient takes a 
deep inspiration, and thus fills the chest, so as to give a point d'appui to 
the abdominal muscles. For the same reason she involuntarily seizes 
hold of some point of support, as the hand of a bystander or a towel 
tied to the bed, and at the same time pushes with her feet against the 
end of the bed, and so is able to bear down to advantage. The cries are 
no longer sharp and loud, but consist of a series of deep suppressed 
groans, which correspond to a succession of short expirations made dur- 
ing the straining eifort. In this way the abdominal muscles contract 
forcibly on the uterus, which they further stimulate to action by press- 
ing upon it. It is to be observed that these straining efforts are, to a 
considerable extent, under the control of the patient. By encouraging 
her to hold her breath and bear down they can be intensified, while if 
we wish to lessen them we can advise her to call out, and when she does 
so the abdominal muscles have no longer a fixed point of action. 
Although the patient may thus lessen the effect of these accessory mus- 
cles, it is entirely out of her power to stop their action altogether. As 
labor advances the head descends lower and lower, receding somewhat in 
the intervals between the pains, until eventually it comes down on the 
perineum, which it soon distends. 

Distension of the Perineum and Birth of the Child. — The pains now 
get stronger and more frequent, often with scarcely a perceptible inter- 
val between them, until the perineum gets stretched by the advancing 
head. In the interval between the pains the elasticity of the perineal 
structures pushes the head upward, so as to diminish the tension to 
which the perineum is subjected, the next pain again putting it on the 
stretch and protruding the head a little farther than before. By this 
alternate advance and recession the gradual yielding of the structures is 
favored and risk of laceration greatly diminished. During this time 
the pressure of the head mechanically empties the bowel of its contents. 
During the last pains, when the perineum is stretched to the utmost, the 



THE PHENOMENA OF LABOR. 265 

anal aperture is dilated, sometimes to the size of a five-shilling piece ; 
and in this way the perineum is relaxed, just as the distension, and con- 
sequent risk of laceration, are at their maximum. The apex of the head 
now protrudes more and more through the vulva, surrounded by the 
orifice of the vagina, and eventually it glides over the perineum and is 
expelled. The intensity of the suffering at this moment generally causes 
the patient to call out loudly.. The force of the abdominal muscles is 
thus lessened at the last moment ; and this, in combination with the 
relaxation of the sphincter ani, forms an admirable contrivance for less- 
ening the risk of perineal injury. The rest of the body is generally 
expelled immediately by a single pain, and with it are discharged the 
remains of the liquor amnii and some blood-clots from separation of the 
placenta ; and so the second stage of labor terminates. 

The Third Stage : Its Importance. — The third stage commences after 
the expulsion of the child. It is of paramount importance to the safety 
of the mother that it should be conducted in a natural and efficient 
manner, for it is now that the uterine sinuses are closed ; and the frail 
barrier by which nature effects this may be very readily interfered with, 
and serious and even fatal loss of blood ensue. Unfortunately, it is too 
often the case that the practitioner's entire attention is fixed on the ex- 
pulsion of the child, so that the natural history of the rest of delivery is 
generally imperfectly studied and understood. 

Contraction of the Uterus and Detachment of the Placenta. — As soon 
as the child is expelled the uterine fibres contract in all directions, and 
the hand, following the uterus down, will find that it forms a firm rounded 
mass lying in the lower part of the abdominal cavity. By retraction of 
its internal surface the placental attachments are generally separated, and 
the after-birth remains in the cavity of the uterus as a foreign body. 

Mode in which Hemorrhage is Prevented. — The escape of blood from 
the open mouths of the uterine sinuses is now prevented in two ways — 
viz. (1) by the contractions of the uterine walls, and the more firm, per- 
sistent, and tonic this is # the more certain is the immunity from hemor- 
rhage; (2) by the formation of coagula in the mouths of the vessels. 
Any undue haste in promoting the expulsion of the placenta tends to 
prevent the latter of these two haemostatic safeguards, and is apt to be 
followed by loss of blood. After a certain time, averaging from a 
quarter to half an hour, the uterus will be felt to harden, and, if tin- 
case be solely left to nature, what has been aptly called a miniature 
labor occurs. Pains come on, and the placenta is spontaneously expelled 
from the uterus, either into the canal of the vagina or even externally. 
In most obstetric works it is stated that the after-birth may be sepa- 
rated either from its centre or ed^c, and that it is very generally 
expelled through the os in an inverted form, with its fcetaJ surface 
downward, and folded transversely on itself. Thai this is the mode in 
which the placenta is often expelled when traction on the cord is prac- 
tised is a matter of certainty. It then passes through the os very much 
in the shape of an inverted umbrella. It is certain, however, that this is 
not the natural mechanism of its delivery. What this is has been well 
illustrated by Duncan, 1 who has very clearly shown that when this stage 
1 Edin. Med. Journ., April, 1871. 



266 



LABOR. 



Fig. 96. 




Mode in which the Pla- 
centa is Naturally Ex- 
pelled. (After Duncan.) 



of labor is left entirely to nature the separated placenta is expelled edge- 
ways, its uterine and detached surface gliding along the inner surface of 
the uterus, the foldings of its structure being parallel to the long diameter 
of the uterine cavity (Fig. 96). In this way it is 
expelled into the vagina, and during the process 
little or no hemorrhage occurs. When the pla- 
centa is drawn out in the way too generally prac- 
tised, it obstructs the aperture of the os, and, acting 
like the piston of a pump, tends to promote hem- 
orrhage. The corollaries as to treatment drawn 
from these facts will be subsequently considered. 
I am anxious, however, here to direct attention 
to Nature's mechanism, because I believe there is 
no part of labor about the management of which 
erroneous views are more prevalent than that of this 
stage, and none in which they are more apt to lead 
to serious consequences ; and unless the mode in 
which Nature effects the expulsion of the placenta 
and prevents hemorrhage is thoroughly understood, 
we shall certainly fail in assisting her in a proper 
manner. In the large proportion of cases, when left 
entirely to themselves, the placenta would be re- 
tained, if not in the uterus, at any rate in the vagi- 
na, for a considerable time — possibly for several hours ; and such delay 
would very unnecessarily tire the patience of the practitioner and be pre- 
judicial to the patient. It is therefore our duty in the majority of cases 
to promote the expulsion of the after-birth ; and when this is properly 
and scientifically done we increase rather than diminish the patient's safety 
and comfort. But in order to do this we must assist Nature, and not 
act in opposition to her method, as is so often the case. 

After-Pains. — When once the placenta is expelled, the uterus con- 
tracts still more firmly, and in a typical case is felt just within the 
pelvic brim, hard and firm and about the size of a cricket-ball. Gen- 
erally for several hours, or even for one or two days, it occasionally 
relaxes and contracts, and these contractions give rise to the " after- 
pains" from which women often suffer much. The object of these 
pains is, no doubt, to expel any coagula that may remain in the uterus ; 
and therefore, however unpleasant they may be to the patient, they must 
be considered, unless very excessive, to be salutary rather than otherwise. 
Duration of Labor. — The length of labor varies extremely in differ- 
ent cases, and it is quite impossible to lay clown any definite rules with 
regard to it. Subject to exceptions, labor is longer in primipara? than 
in multiparas, on account of the greater resistance of the soft parts in 
the former, especially of the structures about the vagina and vulva. It 
is also generally stated that the difficulty of labor increases with the age 
of the patient, and that in elderly primiparse it is likely to be unusually 
tedious from rigidity of the soft parts. It is very doubtful if this 
opinion has any real basis, and in such cases the practitioner often finds 
himself agreeably disappointed in the result, Mr. Roper, 1 indeed, argues 

1 Obst. Trans., v. 7. 



THE PHENOMENA OF LABOR. 267 

that the wasting of the tissues which occurs after forty years of age 
diminishes their resistance, and that first labors after that age are easier, 
as a rule, than in early life. The habits and mode of life of patients 
have no doubt a considerable influence on the duration of labor, but we 
are not in possession of any very reliable facts with regard to this sub- 
ject. It is reasonable to suppose that the tissues of large, muscular, 
strongly-developed women will offer more resistance than those of 
slighter build. On the other hand, women of the latter class, especially 
in the upper ranks of life, more often develop nervous susceptibilities 
which may be expected to influence the length of their labors. The 
average duration of labor, calculated from a large number of cases, is 
from eight to ten hours ; even in priniiparse, however, it is constantly 
terminated in one or two hours from its commencement, and may be 
extended to twenty-four hours without any symptoms of urgency aris- 
ing. In mul ti parse it is frequently over in even a shorter time. Indi- 
cations calling for interference may arise at any time during the progress 
of labor independently of its length. The proportion between the length 
of the first and second stages also varies considerably. The first stage 
is generally the longest ; and it is stated by Cazeaux to be normally 
about twice the length of the second. This is probably under the mark, 
and I believe Joulin to be nearer the truth in stating that the first stage 
should be to the second as four or five to one, rather than as two to one. 
Often when the first stage has been very prolonged the second is termi- 
nated rapidly. 

Necessity of Caution in Expressing an Opinion as to the Possible Dura- 
tion of Labor. — The practitioner is constantly asked as to the probable 
length of labor, and the uncertainty of this should always lead him to 
give a most guarded opinion. Even when labor is progressing appar- 
ently in the most satisfactory manner, the pains frequently die away and 
delivery may be delayed for many hours. In the first stage a cervix 
that is apparently rigid and unyielding may rapidly and unexpectedly 
dilate and delivery soon follow. In either case, if the practitioner has 
committed himself to a positive opinion, he is apt to incur blame, and it 
is far better always to be extremely cautious in our predictions on this 
point. 

Period of the Day at which Labor Occurs. — A somewhat larger pro- 
portion of deliveries occur in the early hours of the morning than at 
other times. Thus, West 1 found that out of. 2019 deliveries, 780 took 
place from lip. m. to 7 a. m., GG2 from 7 A. m. to 3 P. m., and 577 from 
:> p. m. to 11 P.M. 

J Amer. Med. Journ., 1854. 



268 LABOR. 



CHAPTER II. 

MECHANISM OF DELIVERY IN HEAD PRESENTATIONS. 

Importance of the Subject. — It is quite impossible to over-estimate the 
importance of thoroughly understanding the mechanism of the passage 
of the foetus through the pelvis. This dominates the whole scientific 
practice of midwifery, and the practitioner cannot acquire more than a 
merely empirical knowledge, such as may be possessed by an uneducated 
midwife, or conduct the more difficult cases requiring operative interfer- 
ence with safety to the patient or satisfaction to himself, unless he thor- 
oughly masters the subject. 

In treating the physiological phenomena of labor it was assumed that 
we had to do with an ordinary case of head presentation, the description 
being applicable, with slight variations, to presentations of other parts 
of the foetus. So in discussing the mechanical phenomena of delivery 
I shall describe more in detail the mechanism of head presentations, 
reserving any account of the mechanism of other presentations until they 
are separately studied. 

Frequency of Head Presentations. — Head presentation is so much more 
frequent than that of any other part — amounting to 95 per cent, of all 
cases — that this mode of studying the subject is fully justified ; and 
when once the student has mastered tljLe phenomena of delivery in head 
presentations, he will have little difficulty in understanding the mechan- 
ism when other parts of the foetus present, based, as it always is, on the 
same general plan. 

Mode of Recognizing the Position of the Head by its Sutures and Fon- 
tanelles. — In entering on this study w T e come to appreciate the importance 
of the sutures and fontanelles in enabling us to detect the position of the 
foetal head and to watch its progress through the pelvis ; and unless the 
" tactus eruditus " by which these can be distinguished from each other 
has been acquired, the practitioner will be unable to satisfy himself of 
the exact progress of the labor. Nor is this always easy. Indeed, it 
requires considerable experience and practice before it is possible to make 
out the position of the head with absolute certainty ; but this knowledge 
should always be aimed at, and the student will never regret the time 
and trouble he spends in acquiring it. 

Position of the Head at the Commencement of Labor. — At the com- 
mencement of labor the long diameter of the head lies in almost any 
diameter of the pelvic brim except in the antero-posterior, where there 
is not space for it. In the large majority of cases, however, it enters 
the pelvis in one or other of the oblique diameters, or in one behveen the 
oblique and transverse ; but until it has fairly passed through the brim 
it more frequently lies directly in the transverse diameter than has been 
generally supposed. Hence obstetricians are in the habit of describing 
the head as lying in four positions, according to the parts of the pelvis 



DELIVERY IN HEAD PRESENTATIONS. 



269 



to which the occiput points ; the first and third positions being those in 
which the long diameter of the head occupies the right oblique diameter 
of the pelvis, the second and fourth those in which it lies in the left 
oblique. Many subdivisions of these positions have been made, which 
only complicate the subject and render it more difficult to understand. 

the positions, then, of the foetal head after it has entered the brim, 
which it is of importance to be able to distinguish in practice, are : 

First (or left occipito-cotyloid). — The occiput points to the left for- 
amen ovale, the sinciput to the right sacro-iliac synchondrosis, and 
the long diameter of the head lies in the right oblique diameter of the 
pelvis. 

Second (or right occipito-cotyloid). — The occiput points to the right 



foramen ovale, the forehead to the left 



ova 
the long diameter of the head 



iliac synchondrosis, and 



sacro-inac 
ies in the left oblique diameter of the 



pelvis. 

Third (or right occipito-sacro-iliac). — The occiput points to the right 
sacro-iliac synchondrosis, the forehead to the left foramen ovale, and the 
long diameter of the head lies in the right oblique diameter of the pelvis. 
This position is the reverse of the first. 

Fourth (or left occipito-sacro-iliac). — The occiput points to the left 
sacro-iliac synchondrosis, the forehead to the right foramen ovale, and 
the long diameter of the head lies in the left oblique diameter of the pel- 
vis. This position is the reverse of the second. 

The Relative Frequency of these Positions. — The relative frequency of 
these positions has long been, and still is, a matter of discussion among 
obstetricians. According to Xaegele, to whose classical essay we owe 
the greater part of our knowledge of the subject, the head lies in the 
right oblique diameter in 99 per cent, of all cases. More recent 
researches have thrown some doubt on the accuracy of these figures, and 
many modern obstetricians believe that the second position, which Nae- 
gele believed only to be observed as a transitional stage in the natural 
progress of the third position, is much more common than he supposed. 
This question will be more fully discussed when we treat of the mechan- 
ism of occipito-posterior delivery, and, in the mean time, it may serve 
to show the discrepancy which exists in the opinions of modern writers 
if we append the following table of the relative frequency of the various 
positions, 1 copied from Leishman's work : 



Naegele 

Naegele, Jr 

Simpson and I>arry 

Dubois 

Murphy 

Swavne 



First 
Position. 



70. 

64.64 

76.45 

70.83 

63.23 

86.36 



Second 
Position. 



.29 
2.87 

16.18 
9.79 



Third 
Position. 



Fourth 
Position. 



29. 
32.88 
22.68 
25.66 

16.18 
1.04 



.58 
.62 

4.42 

2.8 



Nol 
Classified. 



1. 
2.47 



Here it will be seen that all obstetricians are agreed as to the imrnensely 
greater frequency of the first position, the only poinl al issue being the 
relative frequency of the second and third. 

1 Leish man's System of Midwifery, p. 341. 



270 LABOR. 

Explanation. — Various explanations have been given of the greater 
frequency with which the head lies in the right oblique diameter. By 
some it is referred to the natural tendency of the back of the foetus, as 
shown by the experimental researches of Honing and other writers, to 
be directed, in consequence of gravitation, forward and. to the left side 
of the mother in the erect attitude, and backward and to her right side 
in the recumbent. The explanation given by Simpson was that the 
head lay in the right oblique diameter in consequence of the measure- 
ment of the left oblique being more or less lessened by the presence of 
the rectum. When the rectum is collapsed, indeed, the narrowing of 
the diameter is slight ; but it is so often distended by fecal matter — 
sometimes, when constipation exists, to a very great extent — that it may 
really have a very important influence in determining the position of the 
foetal head. 

In describing the mechanism of delivery it will be well for us to con- 
centrate our attention on the first or most common position, dwelling 
subsequently more briefly on the differences between it and the less 
common ones. 

Description of the First Position. — In this position, when the head 
commences to descend, the occiput lies in the brim pointing to the left 
ileo-pectineal eminence, the forehead is directed to the right sacro-iliac 
synchondrosis, and the sagittal suture runs obliquely across the pelvis in 
the right-oblique diameter. The back of the child is turning toward 



Fig. 9 




Attitude of Child in First Position. (After Hodge.) 

the left side of the mother's abdomen, the right shoulder to her right 
side, the left to her left side (Fig. 97). If a vaginal examination be 
now made (the patient lying in the ordinary obstetric position), and the 
os be sufficiently. open, the finger will impinge upon the protuberance of 
the right parietal bone, which is described as the " presenting part " — a 



DELIVERY IN HEAD PRESENTATIONS. 



271 



term which has received various definitions, the best of which is proba- 
bly that adopted by Tyler Smith : viz. " that portion of the foetal head 
felt most prominently within the circle of the os uteri, the vagina, and 
the os tincse in the successive stages of labor." If the tip of the exam- 
ining finger be passed slightly upward, it will feel the sagittal suture 
running obliquely across the pelvis, and if this be traced downward and 
to the left, it will come upon the triangular posterior fontanelle, with the 
lambdoidal sutures diverging from it. If the finger could be passed 
sufficiently high in the opposite direction, upward and to the right, it 
would come upon the large anterior fontanelle, but at this time that is 
too high up to be within reach. The chin is slightly flexed upon the 
sternum, this flexion, as we shall presently see, being greatly increased 
as the head begins to descend. 

The head, at the commencement of labor, generally lies within the 
pelvic brim, especially in primiparse. In multipara?, owing to the 

Fig. 98. 




Fir-t Position : Movement of Flexion. 



relaxation of the abdominal parietes, the uterus is apt to fall somewhat 
forward, and the head consequently is more entirely above the brim, but 
is pushed within it as soon as labor actually commences. 

Naegelefs Views. — Naegele — and his description has been adopted by 
most subsequent writers — describes the head at this period as lying 
obliquely in relation to the brim, the right parietal hone, on which the 
examining linger impinges, being supposed by him to he much lower 
than the left. The accuracy of this view has of late year- been con- 
tested, and it is now pretty generally admitted thai this obliquity does 
not exist, and that the head enters the brim of the pelvis with both 
parietal hone- on the same level, and with its bi-parietal diameter par- 
allel to the plane of the inlet (Fig. 98). Naegele's view was adopted, 
partly because the finger always felt the right parietal protuberance low- 
est, and partly because it was at that point that the " <-<t/,nf %wxe- 
daneum" or swelling observed on the head after delivery, was always 



272 LABOR. 

formed. Both arguments are, however, fallacious ; for the right pari- 
etal bone is the part which would naturally be felt lowest, on account 
of the oblique position of the pelvis to the trunk ; while, with regard to 
the caput succedaneum, it has been conclusively proved by Duncan that 
it does not form on the point most exposed to pressure, as Naegele 
assumed, but on the part of the head where there is least pressure — that 
is, the part lying over the axis of the vaginal canal. 

Division of Mechanical Movements into Stages. — In tracing the prog- 
ress of the head from the position just described, obstetricians have been 
in the habit of dividing the movements it undergoes into various stages, 
which are convenient for the purpose of facilitating description. It 
must be borne in mind that these are not evident and distinct stages, 
which can always be made out in practice, but that they run insensibly 
into one another, and often occur simultaneously, or nearly so, in rapid 
labor. They may be described as — 1. Flexion; 2. First movement of 
descent ; 3. Levelling or adjusting movement ; 4. Rotation ; 5. Second 
movement of descent and extension ; 6. External rotation. 

1 . Flexion. — The first movement of the head consists of a rotation on 
its bi-parietal diameter, by which the chin of the child becomes bent on 
the sternum and the occiput descends lower than the forehead. By this 
there is a clear gain of at least a half inch, for the occipito-bregmatic 
diameter (3J inches) becomes substituted for the occipito-frontal (4J 
inches) (Fig. 98). 

The movement is most marked when the pelvis is narrow, and in 
some cases of pelvic deformity it takes place to an extreme degree ; 
while in unusually large and roomy pelves it occurs to a very slight 
extent or not at all. The reason of this flexion is twofold. Solayres 
and the majority of obstetricians explain it by saying that the expulsive 
force is communicated to the head through the vertebral column, and 
inasmuch as the head is articulated much nearer the occiput than the 
sinciput, the resistance being equal, the former must be pushed down. 
This is doubtless the correct explanation of the flexion after the mem- 
branes are ruptured ; but before that happens the ovum is practically a 
bag of water, which is equally compressed at all points by the uterine 
contraction, and is pushed downward through the os en masse, the expul- 
sive force not being transmitted through the vertebral column at all. 
Under such circumstances flexion is probably effected in the following 
way : the head being articulated nearer the occiput than the forehead, 
and being equally pressed upon from below by the resisting structures, 
the pressure is more effectual on the forehead ; consequently, that is 
forced upward and the occiput descends. This explanation would also 
hold good after the rupture of the membranes, and probably both causes 
assist in effecting the movement. 

2 and 3. Descent and Levelling Movement. — The movements of descent 
and levelling may be described together. As soon as the head is liberated 
from the os uteri, it descends pretty rapidly through the pelvis until the 
occiput reaches a point nearly opposite the lower part of the foramen 
ovale (Fig. 99) and the sinciput is opposite the second bone of the 
sacrum. A levelling movement now occurs ; the anterior fontanelle 
comes to be more easily within reach, more on a level with the posterior, 



DELIVERY IX HEAD FEESEXTATIOXS. 



273 



and the chin is no longer so much flexed on the sternum. This change 
is due to the fact that the anterior end of the ovoid experiences greater 
resistance than the posterior, and as soon as this resistance counterbal- 
ances and exceeds that applied to the latter, the sinciput must descend. 
The right side of the head also descends .more than the left from a sim- 
ilar cause, so that the head becomes, as it were, slightly flexed on the 
This obliquity of the head on its transverse diameter 

Fig. 



right shoulder. 




First Position : Occiput in the Cavity of the Pelvis. (After Hodge.) 

in the lower part of the pelvis has been denied by Klineke, 1 who main- 
tains that the head passes through the entire pelvis in the same position 
as it enters the brim — that is, with both parietal bones on a level — so 
that the point of intersection of the transverse and antero-posterior 
diameters of the pelvis would correspond with the sagittal suture. There 
is, however, good reason to believe that in the lower half of the pelvic 
cavity the head is not truly synclitic, as Kiineke describes, but that the 
right parietal bone is on a somewhat lower level than the left. 

4. Rotation. — The movement of rotation is very important. By it 
the long diameter of the head is changed from the oblique diameter of 
the pelvic cavity to the antero-posterior diameter of the outlet (Fig. 100), 

Fig. 100. 




First Position: Occiput at Outlet <>f the Pelvis. (After Bod 

or to a diameter nearly corresponding to it, bo that the long diameter of 
the head is brought into relation with the Longest diameter <»i' the pelvic 
outlet. This alteration almost always take- place, and may be readily 
observed by the accoucheur who carefully watches the progress of labor. 
Various explanations have been given of it- causes. The one most gen- 
erally adopted is, that it i- due t«> the projection inward of the ischial 
-pine-, which narrow the transverse diameter of the pelvic outlet. As 
1 Die Via- Factoren der Oeburt, Berlin, 181 

18 



274 LABOR. 

the pains force the occiput downward, its rotation backward is prevented 
by the projection of the left ischial spine, while its rotation forward is 
favored by the smooth bevelled surface of the ascending ramus of the 
ischium. Similarly, the ischial spine on the opposite side prevents the 
rotation forward of the forehead, which is guided backward to the cavity 
of the sacrum by the smooth surface of the sacro-ischiatic ligaments. 
These arrangements, therefore, give a screw-like form to the interior of 
the pelvis ; and as the pains force the head downward, they are effectual 
in imparting to it the rotatory movement which is of such importance in 
adapting it to the longest measurement of the outlet. 

By most of the German obstetricians the influence of the ischial spines 
and of the smooth pelvic planes in producing rotation is not admitted. 
They rather refer the change of direction to the increased resistance the 
head meets from the posterior wall of the pelvis and from the perineal 
structures. Whichever part of the head first meets this resistance, which 
is much greater than that of the interior part of the pelvis, must neces- 
sarily be pressed forward ; and as, in the large majority of cases, the 
posterior fontanelle descends first, it is thus pressed forward until rota- 
tion is effected. This view has the advantage of accounting equally well 
for the rotation in occipito-posterior as in occipito-anterior positions, the 
former of which, on the more ordinarily received theory, are not quite 
satisfactorily explicable. It does not follow that the smooth surfaces of 
the pelvic planes are without influence in favoring the rotation — on the 
contrary, they probably greatly facilitate it — but it is more simply and 
effectually explained by the latter theory than by that which attributes 
so important an action to the ischial spines. 

In some rare cases the head escapes rotation and reaches the perineum 
still lying in the oblique diameter. Even here, however, rotation is gen- 
erally effected, often suddenly, just as the head is about to pass the vulva, 
and it is very rarely expelled in the oblique position. The movement 
at this stage may be explained by the perineum, which is attached at its 
sides and grooved in its centre : to the hollow so formed the long diam- 
eter of the head accommodates itself, and is thus rotated into the antero- 
posterior diameter of the outlet. 

5. Extension. — By the process just described the face is turned back 
into the hollow of the sacrum ; but the head does not lie absolutely in 
the antero-posterior diameter of the pelvic outlet, but rather in one 
between it and the oblique. The occiput is still forced down by the 
pains, and, in consequence of its altered position, is enabled to pass 
between the rami of the pubes, and advances until its further descent is 
checked by the nape of the neck, which is pressed under and against the 
arch of the pubes. By this means the occiput is fixed, and, the pains 
continuing, the uterine force no longer acts on the occiput, but on the 
anterior part of the head, which is now pushed down and separated from 
the sternum. This constitutes extension. As the head descends the soft 
structures of the perineum are stretched and the coccyx pushed back so 
as to enlarge the outlet. The pains continue to distend the perineum 
more and more, the head advancing and receding with each pain. As 
the forehead descends, the sub-occipito-bregmatic, the sub-occipito- 
frontal, and the sub-occipito-mental diameters successively present ; the 



DELIVERY IN HEAD PRESENTATIONS. 



275 



occiput turns more and more upward in front of the pubes (Fig. 101), 
and at last the face sweeps over the perineum and is born. 

The mechanical cause of this movement may be readily explained. 
As soon as the occiput has passed under the arch of the pubis, and is 



Fig. 101. 




First Position : Head Delivered. (After Hodge.) 

no longer resisted by the anterior pelvic walls, the head is subjected to 
the action of two forces — that of the uterine pressure, acting downward 
and backward, and that of the resistance of the posterior walls of the 
pelvis and the soft parts, acting almost directly forward. The necessary 
result is that the head is pushed in a direction intermediate between these 
two opposing forces — that is, downward and forward in the axis of the 
pelvic outlet. 

In addition to the slight obliquity which exists as regards the direct 
relation of the long diameter of the head to the antero-posterior diameter 
of the outlet at the moment of its expulsion, the head also lies somewhat 
obliquely in relation to its own transverse diameter, so that, in the 
majority of cases, the right parietal bone is expelled before the left. 

Fig. 102. 




External Rotatio 



f Heart in First Position. (After Hodge.) 



6. Externa! Rotaticm. — Shortly after the head is expelled, as -non as 
renewed uterine action commences, it may he observed to make a dis- 
tinct rotatory movement, the occiput turning to the lefl thigh of the 
mother, and the face turning upward to the righl thigh ( Fig. 102). The 



276 



LABOR. 



reason of this is evident. When the head descends in the right oblique 
diameter, the shoulders lie in the opposite or left oblique diameter, and as 
the head rotates into the antero-posterior diameter they are necessarily 
placed more nearly in the transverse. As soon as the head is expelled the 
shoulders are subjected to the same uterine force and pelvic resistance as 
the head has just been, and they are acted on in precisely the same way. 
Consequently they too rotate, but in the opposite direction — into the 
antero-posterior diameter of the outlet, or nearly so, just as the head did — 
and as they do so they necessarily carry the head with them and cause 
its external rotation. 

The two shoulders are soon expelled, the left shoulder generally the 
first, sweeping over the perineum in the same manner as the face. This 
is, however, not always the case, and they are often expelled simulta- 



Fm. 103. 




Third Position of Occiput at Brim of Pelvis. 

neously, or the right shoulder may come first. The body soon follows ; 
and the second stage of labor is completed. 

Second Position. — In the second position (right occipito-cotyloid) the 
long diameter of the head lies in the left oblique diameter of the pelvis. 
On making a vaginal examination in the ordinary obstetric position, the 
finger, passing upward and to the right, feels the small posterior fonta- 
nelle ; downward and to the left, it feels the anterior. The sagittal 
suture lies obliquely across the pelvis in the left oblique diameter. The 
description of the mechanism of delivery is precisely the same as in the 
first position, substituting the word left for right. Thus the finger 
impinges on the left parietal bone ; the occiput turns from right to left 
during rotation. After the birth of the head the occiput turns to the 
right thigh of the mother, the face to the left thigh. 

Third or Right Occipito-sacro-iliae Position. — In the third position 
the head enters the pelvic Brim with the occiput directed backward to 
the right sacro-iliac synchondrosis, and the sinciput forward to the left 
foramen ovale (Fig. 103). The posterior fontanelle is directed back- 



DELIVERY IN HEAD PRESENTATIONS. 277 

ward, the anterior fontanelle forward, while the examining finger im- 
pinges on the left parietal bone. The mechanism of delivery in these 
cases is of much interest. In the large majority of cases, during the 
progress of delivery the occiput rotates forward along the right side of 
the pelvis until it comes to lie almost in the antero-posterior diameter of 
the outlet and passes under the pubic arch, the forehead passing over the 
perineum. It will be seen that during part of this extensive rotation 
the head must lie in the second position, and the case terminates just as 
if it had been in the second position from the commencement of labor. 

Manner in which the Occiput is Rotated Forward. — How is it that 
this rotation is effected, and that the sinciput, occupying the position of 
the occiput in the first position, should not be rotated forward to the 
pubes as that is '? This, no doubt, may be explained by the fact that the 
uterine force transmitted through the vertebral column causes the occiput 
to descend lower than the sinciput, so that in most cases, in making a 
vaginal examination, the posterior fontanelle can be readily felt, while 
the anterior is high up and out of reach. The head is therefore extremely 
flexed, and so descends into the pelvic cavity, until the occiput, being 
now below the right ischial spine, experiences the resistance of the pelvic 
floor opposite the right sacro-ischiatic ligament, by which it is directed 
forward. The forehead is at this time, supposing flexion to be marked, 
too high to be influenced by the anterior pelvic plane. Pressure continu- 
ing, the occiput rotates forward, the forehead passes round the left side 
of the pelvis, and labor is terminated as in the second position. 

The period of labor at which rotation takes place varies. In the 
majority of cases it does not occur until the head is on the floor of the 
pelvis, for it is then that resistance is most felt; but the greater the 
resistance, the sooner will rotation be produced. Hence it is more likely 
to occur early when the head is large and the pelvis comparatively small. 

The facility with which this movement is effected obviously depends 
upon the complete flexion of the chin on the sternum, by which the 
anterior fontanelle is so elevated that its rotation backward is not resisted 
by the inward projection of the left ischial spine, and the occiput is cor- 
respondingly depressed. If, however, this flexion is not complete, and 
the anterior fontanelle is so low as to be readily within reach of the fin- 
ger, considerable difficulty is likely to be experienced. In many such 
cases rotation is still eventually effected, but in others it is not ; and the 
labor is then terminated 1 with the face to the pubes, but at the ex- 
pense of* considerable delay and difficulty. According to Dr. Uvedale 
West of Alford, who devoted much careful study to the subject, this 
termination occurs in about 4 per cent, of occipito-posterior positions. 
When it is about to happen the anterior fontanelle may he felt very low- 
down, and sometimes even the forehead and superciliary ridges. The 
uterine force pushes down the occiput, the sinciput being fixed behind 
the pubes, which it obviously cannot pass under, as does the occiput in 
the first position. The sinciput therefore becomes more flexed and 
pushed upward, while the resistance of the pelvic floor direct- the occi- 
put forward. The perineum now becomes enormously distended by the 

back part of the head, and is in greal danger of laceration. The occi- 
put is eventually, but not without much difficulty, expelled. A process 



278 LABOR. 

of extension now occurs, the nape of the neck being fixed, as it were, 
against the centre of the perineum, the expelling force now acting on the 
forehead and producing rotation of the head on its transverse axis. The 
forehead and face are thus protruded, and the body follows without 
difficulty. 

It is said that in a few exceptional cases, where the anterior fontanelle 
is much depressed, the labor may terminate by the conversion of the pres- 
entation into one of the face, the head rotating on its transverse axis, 
the forehead passing to the posterior part of the pelvis, and the chin 
emerging under the perineum. It is obvious, however, that this change 
can only occur when the head is unusually small, and it must of neces- 
sity be extremely rare. 

Relative Frequency of Second and Third Positions. — Reference has 
already been made to Naegele's views as to the rarity of the second posi- 
tion, and to his opinion that cases in which the occiput was found to 
point to the right foramen ovale were only transitional stages in the 
rotation of occipito-posterior positions. Such an assumption, however, 
is unwarrantable unless the case has been watched from the very com- 
mencement of labor. Many perfectly-qualified observers have arrived 
at the conclusion that second positions are far more common than Nae- 
gele supposed ; and in the table already quoted it will be seen that while 
Murphy estimates the second and third as being equally frequent, Swayne 
believes the second to be much more common than the third. It is 
probable that the weight of Naegele's authority has induced many 
observers to classify second positions as third positions in which partial 
rotation has already been accomplished. My own experience would cer- 
tainly lead me to think that second positions are very far from uncom- 
mon. The question, however, must be considered to be in abeyance 

Fig. 104. 




Fourth Position of Occiput at Pelvic Brim. 

until further observations by competent authorities enable us to decide 
conclusively. 

Fourth, or Left Occipito-sacro-Uiac. — The fourth position is just as 
much the reverse of the second as the third is of the first. The occiput 
points to the left (Fig. 104) sacro-iliac synchondrosis, and the finger im- 
pinges on the right parietal bone. The mechanism is precisely the same 
as in the third position, the rotation taking place from left to right. 



DELIVERY IN HEAD PBESEXTATIOXS. 279 

Formation of the Caput Suceedaneum. — The formation of the caput 
sucoedaneum has been already alluded to. This term is applied to the 
(Edematous swelling which forms on the head, and is produced by effusion 
from the obstruction of the venous circulation caused by the pressure to 
which the head is subjected. It follows that the size of the swelling is 
in direct proportion to the length of the labor. In rapid deliveries, in 
which the head is forced through the pelvis quickly, it is scarcely, if at 
all, developed, while after protracted labors it is large and distinct, and 
may obscure the diagnosis of the position by preventing the sutures and 
fontanelles being felt. Its situation varies according to the position of 
the head ; thus, in the first and fourth positions it forms on the right 
parietal bone, in the second and third on the left ; and we may therefore 
verifv, by inspection of its site, the accuracy of our diagnosis. 

An ordinary mistake which has been made by obstetricians is to regard 
the caput suceedaneum as formed at the point where the head has been 
most subjected to pressure ; while, in fact, it forms on that part which 
is most unsupported by the maternal structures, and where the swelling 
may consequently most readily occur. Therefore, in the early stages of 
the labor it always forms on the part of the head which lies in the circle 
of the os uteri ; while in subsequent stages it forms on that which lies 
in the axis of the vaginal canal, and eventually is most prominent on 
the part that is first expelled from the vulva. 

Alteration in the Shape of the Head from Moulding. — A few words 
may be said as to the alteration in the form of the foetal head which 
occurs in tedious labors, and results from the moulding which it has 
undergone in its passage through the pelvis. The smaller the pelvis and 
the greater the pressure applied to the head during delivery, the more 
marked this is. The result is, that in vertex presentations the occipito- 
mental and occipitofrontal diameters are elongated to the extent of an 
inch or even more, while the transverse diameters are lessened, from 
compression of the parietal bones. This moulding is of unquestionable 
value in facilitating the birth of the child. The amount of apparent 
deformity is very considerable, and may even give rise to some anxiety. 
It is well to remember, therefore, that it is always transient, and that in 
a few hours, or days at most, the elasticity of the soft cranial bones 
causes them to resume their natural form. The caput suceedaneum also 
disappears rapidly; therefore, no amount of deformity from cither of 
these causes need give rise to anxiety or call for any treatment. 



280 LABOR. 



CHAPTER III. 
MANAGEMENT OF NATUEAL LABOE. 

Although labor is a strictly physiological function, and in a large 
majority of cases might, no doubt, be safely accomplished without 
assistance from the accoucheur, still, medical aid, properly given, is 
always of value in facilitating the process, and is often absolutely essen- 
tial for the safety of the mother and child. 

Preparatory Treatment. — The management of the pregnant woman 
before delivery is a point which should always receive the attention of 
the medical attendant, since it is of consequence that the labor should 
come on when she is in as good a state of health as possible. For this 
purpose ordinary hygienic precautions should never be neglected in the 
latter months of gestation. The patient should take regular and gentle 
exercise, short of fatigue, and, if the weather permit, should spend as 
much of her time as possible in the open air. Hot rooms, late hours, 
and excitement of all kinds should be strictly avoided. The diet should 
be simple, nutritious, and unstimulating. The state of the bowels 
should be particularly attended to. During the few days preceding 
labor the descent of the uterus often causes pressure on the rectum and 
prevents its evacuation. Hence it is customary to prescribe occasional 
gentle aperients, such as small doses of castor oil, for a few days before 
the expected period of delivery. Some caution, however, is necessary, 
as it is certainly not very uncommon for labor to be determined rather 
sooner than was anticipated in consequence of the irritation of too large 
a purgative dose. The state of the bowels should always be inquired 
into at the commencement of labor, and if there be any reason to sus- 
pect that they are loaded a copious enema should be administered. This 
is always a proper precaution to take, for a loaded rectum is a common 
cause of irregular and ineffective uterine action ; and even when it does 
not produce this result, the escape of the feces, in consequence of pres- 
sure on the bowel during the propulsive stage, is always disagreeable 
both to the patient and practitioner. 

Dress of Patient during Pregnancy. — The dress of the patient during 
pregnancy may be here adverted to, for much discomfort may arise, and 
the satisfactory progress of labor may even be interfered with, from 
errors in this respect. 

After the uterus has risen out of the pelvis the ordinary corset which 
most women wear is apt to produce very injurious pressure ; still more 
so when attempts are made to conceal the increased size by tight-lacing. 
After the fourth or fifth month, therefore, the comfort of the patient is 
much increased by wearing a specially-constructed pair of stays with 
elastic let into the sides and front, so that they accommodate themselves 
to the gradual increase of the figure. Such are made by all stay-makers, 
and should be worn whenever the circumstances of the patient permit. 



MANAGEMENT OF NATURAL LABOR. 281 

Failing this, it is better to avoid the use of the corset altogether, and to 
have as little pressure on the uterus as possible, although many women 
cannot do without the support to which they are accustomed. To mul- 
tipara?, especially if there be much laxity of the abdominal parietes, a 
well-fitting elastic abdominal belt is often a great comfort. This is con- 
structed so that it can be tightened when the patient is walking and in 
the erect position, when such support is most required, and readily 
loosened when desired. 

Necessity of Attending to the First Summons. — It is hardly necessary 
to insist on the necessity of the practitioner attending immediately to 
the first summons to the patient. It is true that he may very often be 
sent for long before he is actually required. But, on the other hand, it 
is quite impossible to foresee what may be the state of any individual 
case. By prompt attention he may be able to rectify a malposition or 
prevent some impending catastrophe, and thus save his patient from 
consequences of the utmost gravity. 

Articles to be Taken by the Accoucheur. — The practitioner should 
always be provided with the articles which he may require. The 
ordinary obstetric cases, containing one or two bottles and a catheter, 
such as are sold by most instrument-makers, are cumbrous and useless, 
while " obstetric bags" are expensive luxuries not within the reach of 
all. Every one can manufacture an excellent obstetric bag for himself, 
at a small expense, by having compartments for holding bottles stitched 
on to the sides of an ordinary leather bag, such as is sold for a few 
shillings at any portmanteau-maker's. It is a great comfort to have at 
hand all that may be required, and the bag should contain chloroform 
or other anaesthetic, chloral, laudanum, the liquor ferri perchloridi of 
the Pharmacopoeia, the liquid extract of ergot, and a hypodermic 
syringe, with bottles containing ether and a solution of ergotin for 
subcutaneous injection. If it also contain a Higginson's syringe, a 
small elastic catheter, a good pair of forceps, and one or two suture- 
needles, with some silver wire or carbolized catgut, the practitioner is 
provided against any ordinary contingency. Other, articles that may be 
required, such as thread, scissors, and the like, are generally provided 
by the nurse or patient. 

Duties on First Visiting the Patient. — On. arriving at the house the 
practitioner should have his visit announced to the patient ; and he 
will very often find that the first effect of his presence is to arrest 
the pains that have been hitherto progressing rapidly, thereby afford- 
ing a very conclusive proof of the influence 01 mental impressions 
on the progress of labor. If the pains he not already propulsive, it is 
well that Ik; should occupy himself at first in general Inquiries from the 
attendants as to tin; progress of the labor, and in seeing that all tin- 
necessary arrangements are satisfactorily carried out, so as to allow the 
patient time to get accustomed to his presence. If he have any choice 
in the matter, he should endeavor to secure a large, airy, and well- 
ventilated apartment for the lying-in room, as far removed as possible 
from without. He may also see to the lied, which should he without 
curtains and prepared for the labor by having a water-proof sheeting 
laid under a folded blanket or sheet, on which the patient lies. These 



282 „ 



LABOR. 



receive the discharges during labor, and can be pulled from under the 
patient after delivery, so as to leave the dry clothes beneath. Among 
the lower classes the lying-in chamber is considered a legitimate meeting- 
place for numerous female friends to gossip, whose conversation is often 
distressing, and is certainly injurious, to a woman in the excitable con- 
dition associated with labor. The medical attendant should therefore 
insist on as much quiet as possible, and should allow no one in the room 
except the nurse and some one friend whose presence the patient may 
desire. The husband's presence must be left to the wishes of the patient. 
Some women like their husbands to be with them, while others prefer to 
be without them, and the medical attendant is bound to act in accord- 
ance Avith the patient's desire. 

Vaginal Examination. — If pains be actually present, a vaginal exam- 
ination is essential, and should not be delayed. It enables us to ascertain 
whether the labor has commenced or not, and whether the presentation 
is natural or otherwise. The pains, although apparently severe, may be 
altogether spurious, and labor may not have actually commenced. It 
is of much importance, for both our own credit and comfort, that we 
should be able to diagnose the true character of the pains ; for if they 
be so-called " false" pains, we might wait hours in fruitless expectation 



Fig. 105. 




Examination during the First Stage. 



of progress, while delivery is still far off. The necessity of ascertaining, 
therefore, the actual state of affairs need not further be insisted on. 

Character of False Pains. — False pains are chiefly characterized by 
their irregularity, sometimes coming on at short intervals, sometimes 
with many hours between them ; they also vary much in intensity, some 
being very sharp and painful, while others are slight and transient. In 
these respects they differ from the true pains of the first stage, which are 



MANAGEMENT OF NATURAL LABOR. 283 

at first slight and short, and gradually recur with increased force and 
regularity. The situation of the two kinds of pains also varies, the false 
pains being chiefly situated in front, while the true pains are felt most in 
the back and gradually shoot round toward the abdomen. Nothing 
short of a vaginal examination will enable us to clear up the diagnosis 
satisfactorily. If the labor have actually commenced, the os will be 
more or less dilated and its edges thinned, while with each pain the 
cervix will become rigid and the membranes tense and prominent. The 
false pains, on the contrary, have no effect on the cervix, which remains 
flaccid and undilated, or, if the os be sufficiently open to admit the tip 
of the finger, the membranes will not become prominent during the con- 
traction. Under such circumstances we may confidently assure the pa- 
tient that the pains are false, and measures should be taken to remove 
the irritation which produces them. In the large majority of cases the 
cause of the spurious pains will be found to be some disordered state 
of the intestinal tract ; and they will be best remedied by a gentle 
aperient — such as castor oil or the compound colocynth pill with hvos- 
cyamus — followed by, or combined with, a sedative, such as twenty 
minims of laudanum or chlorodyne. Shortly after this has been admin- 
istered the false pains will die away, and not recur until true labor 
commences. 

Mode of Conducting a Vaginal Examination. — For a vaginal exam- 
ination the patient is placed by the nurse on her left side, close to the 
edge of the bed, with the legs flexed on the abdomen. The practitioner, 
being seated by the edge of the bed, passes the index finger of the right 
hand, previously lubricated with carbolized oil or cold cream, up to the 
vulva, and gently insinuates it into the orifice of the vagina, then pushes 
it backward in the axis of the vaginal outlet, and finally turns it upward 
and forward so as to more readily reach the cervix. This it may not 
always be easy to do, for at the commencement of labor the cervix may 
be so high as to be reached with difficulty, or it may be directed back- 
ward so as to point toward the cavity of the sacrum. The exploration 
is often much facilitated by depressing the uterus from without by the 
left hand placed on the abdomen. Our object is not only to ascertain 
the stale of the cervix as to softness and dilatation, but also the presen- 
tation, the condition of the vagina, and the capacity of the pelvis. The 
examination is generally commenced during a pain, at which time it is 
less depressing to the patient ; hut in order to be satisfactory the finger 
must remain in the vagina until the pain is over, the examination being 
concluded in the interval between this pain and the next. 

In head presentations the round mass of the cranium is generally at 
once felt thorough the lower part of the uterus, and then we have the sat- 
isfaction of being able to assure the patient that all i- right. If the os 
be sufficiently dilated, we can also feel through it the occiput covered by 
the membranes. It i- impossible at this time t<> make out the exad posi- 
tion of the head by mean- of the sutures and fontanelles, which are too 
high up to be within reach. Nor should any attempt In- made to do -<», 

for fear of prematurely rupturing the membranes. The fad that the 

head is presenting is all that we require to know at this stage of the labor. 

The Condition of the Os as Indicating the Progress of Labor. — The 



284 LAB OB. 

condition of the os itself, as to rigidity and dilatation, will materially 
assist us in forming an opinion as to the progress and probable duration 
of the labor ; but, although the friends will certainly press for an opin- 
ion on this point, the cautious practitioner will be careful not to commit 
himself to a positive statement, which may so easily be falsified. It will 
suffice to assure the friends that everything is satisfactory, but that it is 
impossible to say with any certainty how rapidly, or the reverse, the case 
may progress. 

If the pains be not very frequent or strong, and the os not dilated to 
more than the size of a shilling, a considerable delay may be anticipated, 
and the presence of the medical attendant is useless. He may, therefore, 
safely leave the patient for an hour or more, provided he be within easy 
reach. It is needless to say that this should never be done unless the 
exact presentation be made out. If some part other than the head be 
presenting, it will probably be impossible to make it out until dilatation 
has progressed further ; and the practitioner must be incessantly on the 
watch until the nature of the case be made out, so as to be able to seize 
the most favorable moment for interference, should that be necessary. 

Position of Patient during First Stage. — The position of the patient 
is a matter of some moment in the first stage. It is a decided advantage 
that she should not be then in a recumbent position on her side, as is 
usual in the second stage ; for it is of importance that the expulsive force 
should act in such a way as to favor the descent of the head into the pel- 
vis — i. e. perpendicularly to the plane of its brim — and also that the 
weight of the child should operate in the same way. Therefore, the 
ordinary custom of allowing the patient to walk about or to recline in 
a chair is decidedly advantageous ; and it will often be observed that 
the pains are more lingering and ineffective if she lie in bed. If the 
patient be a multipara, or if the abdomen be somewhat pendulous, an 
abdominal bandage, by supporting the uterus, will greatly favor the 
progress of this stage. Keeping the patient out of bed has the further 
advantage of preventing her being unduly anxious for the termination 
of the labor ; and a little cheerful conversation will keep up her spirits 
and obviate the mental depression which is so common. 'Good beef-tea 
may be freely administered, with a little brandy and water occasionally 
if the patient be weak, and will be useful in supporting her strength. 

Vaginal Examinations. — Over-frequent vaginal examinations at this 
period should be avoided, for they serve no useful purpose and are apt to 
irritate the cervix. It will be necessary, however, to ascertain the prog- 
ress of the dilatation at intervals. 

Artificial Rupture of the Membranes. — When once the os is fully dila- 
ted, the membranes may be artificially ruptured if they have not broken 
spontaneously, for they no longer serve any useful purpose, and only 
retard the advent of the propulsive stage. This can be easily done by 
pressing on them, when they are rendered tense during a pain, by some 
pointed instrument, such as the end of a hairpin, which is always at 
hand. In some cases, indeed, it is even expedient to rupture the mem- 
branes before the os is fully dilated. Thus, it not unfreqiiently happens, 
when the amount of liquor amnii is at all excessive, that the os dilates 
to the size of a five-shilling piece or more ; but, although it is perfectly 



MANAGEMENT OF NATURAL LABOR. 285 

soft and flaccid, it opens up no farther until the liquor amnii is evacu- 
ated, when the propulsive pains rapidly complete its dilatation. Some 
experience and judgment is required in the detection of such cases, 
for if we evacuate the liquor amnii prematurely the pressure of the 
head on the cervix may produce irritation and seriously prolong the 
labor. This manoeuvre is most likely to be useful when the pains are 
strong and the os perfectly flaccid, and when the membranes do not 
protrude through the os and effect further dilatation. 

It is sometimes not easy to ascertain whether the membranes are rup- 
tured or not. This is most likely to be the case when the head is low 
down and the amount of liquor amnii is so small that the pouch does 
not become prominent during the pains. A little care, however, will 
enable us, if the membranes be ruptured, to feel the rugosities of the 
scalp covered with hair, and to distinguish it from the smooth polished 
surface of the membranes. 

Treatment of the Propulsive Stage. — After the evacuation of the liquor 
amnii there is generally a lull in the progress of the labor, the pains, 
however, soon recurring with increased force and frequency, and propel- 
ling the head through the pelvic cavity. The change in the character 
of the pains is soon appreciated by the bearing-down efforts by which 
they are accompanied, as well as by their increased length and intensity. 

Position of the Patient during the Second Stage. — It is now advisable 
that the patient be placed in bed ; and in this country it is usual for her 
to lie on her left side, with her nates parallel to the edge of the bed and 
her body lying across it. This is the established obstetric position in 
England, and it would be useless to attempt to insist on any other, even 
if it were advisable. Although the dorsal position is preferred on the 
Continent, it is difficult to see wherein its advantages consist. It cer- 
tainly leads to unnecessary exposure of the person, and it is, on the whole, 
less easy to reach the patient, so placed, for the necessary manipulations. 
Moreover, the dorsal position increases the risk of laceration of the per- 
ineum, by bringing the weight of the child's head to bear more directly 
upon it. Thus, Schroeder found that lacerations occurred in 37.6 per 
cent, of cases delivered on the back, as against 24.4 per cent, in other 
positions. 

The patient usually remains in bed during the whole of this stage, 
and it is customary for the nurse to tie to the foot of the bed a jack- 
towel, which is laid hold of and used as a support in making bearing- 
down efforts. If the pains be few and far between, and the patient finds 
it more comfortable to get up occasionally, there is no reason why she 
should not do so. On the contrary, as we shall subsequently see in treat- 
ing of lingering labor, the pains under such circumstances are often 
increased in the sitting posture, in consequence of the weight of the child 
producing increased pressure on the uerves of the vagina. 

Detection of the Position of Head. — At this time vaginal examination, 
which should' be more frequently repeated than in the (irs1 stage, enables 
us to ascertain precisely the position of the head by means of thesutures 
and fontanelles, as well as to watch its progress. 

Management of the Anterior Lip of Cervix when Impacted between the 
Head and Pelvis. — Jt not (infrequently happens that the head descends 



286 LABOR. 

into the pelvis, even to its floor, without the os having entirely disap- 
peared. The anterior lip especially is apt to get caught between the 
head and pubes, to become swollen by the pressure to which it is sub- 
jected, and then to retard the progress of the labor. There can be no 
reasonable objection to attempting to prevent this cause of delay by 
pressing on the incarcerated lip during the interval of the pains, so as 
to push it above the head, and maintain it there during the pains until 
the head descends below it. This manoeuvre, if done judiciously and 
without any undue roughness or force, is certainly not liable to be 
attended by any of the evil consequences which many obstetricians have 
attributed to it : it is, indeed, a matter of common sense that the injury 
to the cervix is likely to be less if it be pushed gently out of the way 
than if it be left to be tightly jammed for hours between the presenting 
part and the bony pelvis. This mode of assistance is very different from 
the digital dilatation of a rigid cervix, which was formerly much prac- 
tised, especially in Edinburgh, in consequence of the recommendation of 
Hamilton, and which was properly objected to by the great majority of 
obstetricians. 

If the pains be producing satisfactory progress, no further interference 
is required. The medical attendant should, however, see that the blad- 
der is evacuated ; and if it have not been so for some hours, it may be 
necessary to draw off the urine by the catheter. Whenever the labor is 
lengthy he should occasionally practise auscultation, so as to satisfy him- 
self that the foetal circulation is being satisfactorily carried on. 

Regulation of the Voluntary Bearing-down Efforts. — The regulation 
of the bearing-down efforts at this time is of importance. It is common 
for the nurse to urge the patient to help herself by straining ; and it is 
certain that by voluntary action of this kind she can materially increase 
the action of the accessory muscles of parturition. If the pains be 
strong and the labor promise to be rapid, such voluntary exertions are 
not likely to be prejudicial. On the other hand, if the case be progress- 
ing slowly they only unnecessarily fatigue the patient, and should be 
discouraged. When the perineum is distended we may even find it 
advisable to urge the patient to cease all voluntary effort, and to cry ou£, 
for the express purpose of lessening the tension to which the perineum 
is subjected. This is the stage in which anaesthesia is most serviceable, 
but its employment must be separately discussed. 

Distension of the Perineum. — As the head descends more and more 
the perineum becomes distended, and there is considerable difference of 
opinion amongst accoucheurs as to the management of the case at this 
time. In most obstetric works the practitioner is advised to endeavor to 
prevent laceration by the manoeuvre that is described as " supporting the 
perineum." By this is meant, laying the palm of the hand on the dis- 
tended structures and pressing firmly upon them during the acme of the 
pain, with the view of mechanically preventing their tearing. There 
can be little doubt that this, or some modification of it, is the practice 
now followed by the large majority of practitioners. Of late years the 
evil effects likely to follow it have been specially dwelt upon by Graily 
Hewitt, Leishman, Goodell, and other writers, who maintain that by 
pressure exerted in this fashion we not only fail to prevent, but actually 



MANAGEMENT OF NATURAL LABOR. 287 

favor, laceration, in consequence of the pressure producing increased ute- 
rine action just at the time when forcible distension of the perineum is 
likely to be hurtful. Therefore, some hold that the perineum ought to 
be left entirely alone, and that the head should be allowed gradually to 
distend it, without any assistance on the park of the practitioner. 

Much error may be traced to a misconception of what is required. 
The term " supporting the perineum " conveys an unquestionably errone- 
ous idea, and it is certain that no one can prevent laceration by mechani- 
cal support. If the term " relaxation of the perineum " was employed, 
we should have a far more accurate idea of what should - be aimed at, 
and if this be borne in mind I think it cannot be questioned that nature 
may be most usefully assisted at this stage. 

Dr. GoodeWs Method. — Dr. Goodell of Philadelphia has specially 
studied this subject, and has recommended a method the object of which 
is to relax the perineum. His advice is, that one or two fingers of the 
left hand should be inserted into the rectum, by which the perineum 
should be hooked up and pulled forward over the head, toward the 
pubes, the thumb of the same hand being placed on the advancing head, so 
as to restrain its progress if needful. I have adopted this plan frequently, 
and believe that it admirably answers its purpose, especially when the 
perineum is greatly distended and laceration is threatened. It must be 
admitted that the insertion of the fingers into the anal orifice, in the 
manner recommended, is repugnant both to the practitioner and patient, 
and the same result can be obtained in a less unpleasant way. I men- 
tion it, however, to show what it is that the practitioner must aim at. 
If, when the head is distending the perineum greatly, the thumb and 
fore finger of the right hand are placed along its sides, it can be pushed 
gently forward over the head at the height of the pain, while the tips of 
the fingers may at the same time press upon the advancing vertex, so as 
to retard its progress if advisable (Fig. 106). By this means the sudden 
and forcible stretching of the perineal structures is prevented, and the 
chance of laceration reduced to a minimum, while nature's mode of 
relaxing the tissues, by dilatation of the anal orifice, is favored. This 
is very different from the mechanical support that is usually recom- 
mended, and the less pressure that is applied directly to the perineum 
the better. Xor is it either needful or advisable to sit by the patient 
with the hand applied to the perineum for hours, as is so often practised. 
Time should be given for the gradual distension of the tissues by the 
alternate; advance and recession of the head, and we need only intervene 
to assist relaxation when the stretching has reached its height and the 
head is about to be expelled. A napkin may be interposed between the 
hand and the skin for the purpose of cleanliness. Should the perineum 
be excessively tough and resistant, assiduous fomentation with a hot 
sponge may be resorted to, and will be of some service in promoting 
relaxation. 

Incision of the Perineum. — When the tension IS 30 greal that lacera- 
tion seems inevitable, it is generally recommended that a slight incision 
should be made on each side of the central raphe*, with the view of pre- 
venting spontaneous laceration. This may no doubt be done with per- 
fect safety, but I question if it is likely t<» he of use. 'flic idea is that 



288 LABOR. 

an incised wound is likely to heal more readily than a lacerated one. 
When, however, a distended perineum ruptures, its structures are so 
thinned that the tear is always linear, and, as a matter of fact, the edges 
of the tear are always as clean and as closely in apposition as if the cut 
had been made with a knife. Moreover, the laceration invariably heals 

Fig. 106. 




Mode of Effecting Relaxation of the Perineum. 

perfectly if only the edges be brought into contact at once with one or 
two metallic sutures. I believe, therefore, that Goodell is right in stat- 
ing that incision of the perineum is rarely, if ever, necessary, unless it 
is hardened by previous cicatrization. In almost all first labors the four- 
chette is torn, but requires no treatment of any kind. In some cases, 
do what we will, more or less laceration occurs, and the perineum should 
always be examined after the expulsion of the child to see if any tear 
has taken place. 

Treatment of Lacerations. — If it has given way to any extent, I 
believe that it is good practice to insert one or two interrupted sutures 
of silver wire or carbolized gut at once. Immediately after delivery the 
sensibility of the tissues is deadened by the distension to which they 
have been subjected, and the sutures can be inserted with little or no 
pain. It is quite true that lacerations of an inch or less will generally 
heal perfectly well of themselves, but this is not invariably the case, 
while healing almost certainly follows if the edges be brought together 
at once. In the severer forms of laceration, extending back to, or even 
through, the sphincter, the precaution is all the more necessary, and a 
subsequent operation of gravity may in this way be avoided. The 
sutures can be removed without difficulty in a week or so, when com- 
plete adhesion has taken place. 

Expulsion of the Child. — The head, when expelled, should be received 
in the palm of the right hand, while the left hand is placed upon the 
abdomen to follow down the uterus as it contracts and expels the body. 



MANAGEMENT OF NATURAL LABOR. 289 

There is generally some little delay after the expulsion of the head, and 
we should now see if the cord surround the neck, and if it does so it 
should be drawn over the head ; and, if this is not possible, it may be 
tied and divided between the ligatures. The expulsion of the body 
should be left entirely to the uterine contractions. If there be undue 
delay, we may endeavor to excite uterine action by friction on the 
fundus, and it will rarely happen that sufficient contraction does not 
now come on. If we display undue haste in withdrawing the body, we 
run the risk of emptying the uterus while its tissues are relaxed, and so 
favor hemorrhage. If, however, there seem serious danger of the child 
being asphyxiated, its expulsion may be favored by gently passing the 
fore finger of each hand within the axillae and using traction ; but it is 
only very exceptionally that such interference is required. 

Promotion of Uterine Contraction after the Birth of the Child. — As 
the uterus contracts it should be carefully followed down through the 
abdominal parietes by the left hand, which should grasp it as the body 
is expelled, with the view of seeing that it is efficiently contracted. 
This is a point of vital importance in preventing hemorrhage, which 
will presently be more especially considered. 

Ligature of the Cord. — As soon as the child cries we may proceed to 
tie and separate the cord. For this purpose the nurse usually provides 
ligatures composed of several strands of whitey-brown thread, but tape 
or any other suitable material may be employed. It is important, 
especially if the cord be very thick and gelatinous, to see that it is thor- 
oughly compressed, so that the vessels are obliterated, otherwise second- 
ary hemorrhage might occur. The cord is tied about an inch and a 
half from the child, and it is usual, though of course not essential, to 
place a second ligature about two inches nearer the placental extremity 
of the cord. The latter is perhaps of some use by retaining the blood, 
and thus increasing the size of the placenta and favoring its more ready 
expulsion by uterine contraction. The cord is then divided with scis- 
sors between the ligatures, the child wrapped up in flannel, and given 
to the nurse or a bystander to hold, while the attention of the practi- 
tioner is concentrated on the mother with a view to the proper man- 
agement of the third stage of labor. The researches of Budin, 1 Ivibc- 
mont, 2 and others show that there is a distinct advantage in not tying 
the cord until the child has cried lustily, as the act of respiration 
tends to withdraw the placental blood, and thus increases the entire 
amount of blood in the foetus. It is said that after late ligature of 
the cord the child is more vigorous and active than when it is tied 
too early. 

Treatment of the Cord by Laceration. — The cord may, if preferred, be 
treated with perfect safety by laceration. This method was 6rs1 brought 
under my notice by my friend Dr. Stephen, who lias employed it for 
many years and in several hundred cases. The cord is twisted round 
the index fingers of both hands and torn through, the lacerated vessels 
retracting without any hemorrhage. It is a close imitation of the 
method instinctively adopted bv the lower animals, who gnaw the cord 
asunder, and has the advantage of dispensing with Ligatures altogether. 

1 Budin, Prog res medicate, 187G. 2 Archie, de T<>s<>ln<;., Oct., 1879. 

19 



290 LABOR. 

I have used it myself in a large number of cases, but prefer, on the 
whole, the plan usually adopted. 

Importance of Proper Management of Third Stage. — There is unques- 
tionably no period of labor where skilled management is more important 
and none in which mistakes are more frequently made. By proper care 
at this time the risk of post-partum hemorrhage is reduced to a min- 
imum, the efficient contraction of the uterus is secured, the amount and 
intensity of after-pains are lessened, and the safety and comfort of the 
patient greatly promoted. Moreover, the general practice as to the 
management of this stage is opposed to the natural mechanism of pla- 
cental expulsion, and is far from being well adapted to secure the 
important objects which we ought to have in view. Let us see what is 
the practice usually recommended and followed, and then we shall be in 
a position to understand in what respects it is erroneous. For this pur- 
pose I cannot do better than copy the directions contained in one of 
our most deservedly popular obstetric text-books, which undoubtedly 
expresses the usual practice in the management of this stage : " When 
the binder is applied the patient may be allowed to rest a while if there 
is no flooding ; after which, when the uterus contracts, gentle traction 
may be made by the funis to ascertain if the placenta be detached. If 
so, and especially if it be in the vagina, it may be removed by continu- 
ing the traction steadily in the axis of the upper outlet at first, at the 
same time making pressure on the uterus." 1 

[In this country, for many years, the uniform teaching has been that 
the binder should not be applied until the uterus has expelled the pla- 
centa and become firmly contracted. Although the plan of expression 
was not carried out as completely as is now taught under the Cred6 
method, that of stimulating the contractions of the uterus by manipula- 
tion and pressure was certainly in use forty years ago. When the size 
and solidity of the uterus, as ascertained by the compressing hand, indi- 
cate that the placenta has been expelled into the vagina, it is a question 
whether we shall cause it to be forced through the vulva by pressing 
down the uterus upon it, or make traction upon it by the finger hooking 
down its edge. Occasionally, we find a patient who is very sensitive to 
pressure made upon her uterus after it has become firmly contracted ; 
and in such a case it may be well to depend partly upon traction for 
completing the delivery of the secundines. That it is possible for the 
uterus to expel the placenta suddenly from the vagina where no pressure 
has been made is evident from the fact that a physician of this city, who 
was making traction upon the cord under the old method some years 
ago, was surprised to find the placenta shoot out from the vulva and 
dangle by the funis as he held it in his hand. In such a case the uterus 
must have been aided during a contraction by voluntary abdominal 
pressure, causing the os to descend nearly to the vulva. It is very evi- 
dent that the uterus is subject to muscular fatigue and to the exhaustion 
of its contractile power when long in action ; hence, there is a greater 
risk of uterine atony and hemorrhage after a long labor than a short 
one, and we may expect a more complete expulsion of the placenta in 
the latter. It is also clear, from cases in my oavu experience, that the 

1 Churchill's Theory and Practice of Midwifery, p. 162. 



MANAGEMENT OF NATURAL LABOR. 



291 



muscular power of the uterus is by no means in proportion to the gen- 
eral strength of the woman. The power to assist by bearing down no 
doubt is, but the independent power of the organ itself does not appear 
to be. Certainly some of the most perfect in parturient power that 
have come under my care were small women, with little general mus- 
cular force. One little woman of 86 pounds weight appeared almost 
to have escaped the curse pronounced upon Eve; and another, still 
smaller, expelled a placenta from her vagina almost without any loss 
of blood. — Ed.] 

Objections to Ordinary Practice. — This may fairly be taken as a suffi- 
ciently accurate description of the practice usually followed. 1 The 
objections I have to make are : (1) That it inculcates the common error 
of relying on the binder as a means of promoting uterine contraction, 
advising its application before the expulsion of the placenta ; while I 
hold that the binder should never be applied until after the placenta is 
expelled, and not even then unless the uterus is perfectly and perma- 
nently contracted. (2) That it teaches that traction on the cord should 
be used as a means of withdrawing the placenta, whereas the uterus 
itself should be made to expel the after-birth, and in nineteen cases out 
of twenty the finger need never be introduced into the vagina after the 
birth of the child, nor the cord touched. This may seem an exaggerated 
statement to those who have accustomed themselves to the usual method 
of dealing with the placenta ; but I feel confident that all who have 
learnt the method of expression of the placenta would testify to its 
accuracy. 

Expression of the Placenta. — The cardinal point to bear in mind is, 

1 This practice is further illustrated by the annexed diagram, contained in most 
obstetric works, which represents the accoucheur as withdrawing the placenta by trac- 
tion, and which I insert as an illustration of what ought not to be done (Fig. 107; : 

Fig. 107. 




Usual Method of Removing the Placenta by Traction on the Cord. 



292 LABOR. • 

that the placenta should be expelled from the uterus by a vis a tergo, not 
drawn out by a vis afronte. That uterine pressure after the birth of 
the child has been recommended by many English writers is certain, and 
the Dublin school especially have dwelt on its importance as a prevent- 
ive of post-partum hemorrhage ; but the distinct enunciation of the doc- 
trine that the placenta should be pressed, and not drawn, out of the 
uterus, we owe to Crede and other German writers ; and it- is only of 
late years that this practice has become at all common. Those who 
have not seen placental expression practised find it difficult to under- 
stand that in the large majority of cases the uterus may be made to 
expel the placenta out of the vagina ; but such is unquestionably the 
fact. A little practice is no doubt necessary to effect this satisfactorily ; 
but when once the knack has been learnt, there is little difficulty likely 
to be experienced. 

Importance of Not Removing the Placenta Hurriedly. — Before describ- 
ing the method of placental expression a word of caution may be said 
against undue haste in attempting expression of the placenta — a mistake 
that is often made, and which, I believe, tends to increase the risk of 
post-partum hemorrhage. So long as we satisfy ourselves that the 
uterus is fairly contracted, so as to avoid the possibility of its 'distension 
with blood, a certain delay after the birth of the child is useful, from its 
giving time for coagula to form within the uterine sinuses, by which 
their open mouths are closed up. The importance of this point has been 
specially dwelt upon by McClintock, who lays down the rule that fifteen 
or twenty minutes should be allowed to elapse after the birth of the 
child before any attempt to remove the after-birth is made. This is a 
good and safe practical rule, as it gives ample time for the comjolete 
detachment of the placenta and the coagulation of the blood in the 
uterine sinuses. 

Mode of effecting Expression of the Placenta. — -During this interval 
the practitioner or nurse should sit by the bedside, with the hand on 
the uterus to secure contraction and prevent distension, but not knead- 
ing or forcibly compressing it. When we judge that a sufficient time 
has elapsed we may proceed to effect expulsion. For this purpose the 
fundus should be grasped in the hollow 1 of the left hand, the ulnar edge 
of the hand being well pressed down behind the fundus, and when the 
uterus is felt to harden strong and firm pressure should be made down- 
ward and backward in the axis of the pelvic brim. If this manoeuvre 
be properly carried out and sufficiently firm pressure made, in almost 
every case the uterus may be made to expel the placenta into the bed, 
along with any coagula that may be in its cavity (Fig. 108). The 
uterine surface of the placenta is generally expelled first, as is repre- 
sented in the diagram, the cord being within the membranes j whereas 
the foetal surface and root of the cord are the parts which appear first 
when the placenta is removed by traction (Fig. 107). If we do not 
succeed at the first effort, which is rarely the case if extrusion be not 
attempted too soon after the birth of the child, we may wait until 
another contraction takes place, and then reapply the pressure. I repeat 
that, after a little practice, the placenta may be entirely expelled in this 
way, in nineteen cases out of twenty, without even touching the cord, 



MANAGEMENT OF NATURAL LABOR. 



293 



and the bugbear of retained placenta will cease to be a source of 
dread. 

Should we fail in causing the uterus to expel the placenta, a vaginal 
examination may be made, and, if the placenta be found lying entirely 
in the vagina, it may be carefully withdrawn. If, however, the cord 
can be traced up through the os, showing that the placenta is still within 
the uterine cavity, we must again resort to pressure to effect its expul- 
sion, and not attempt to withdraw it by traction. Such cases may 
fairly be classed as retained placenta, but they should be very rarely 
met with, and are discussed elsewhere. When they do occur often in 
the hands of the same practitioner, it is fair to conclude that he has 
not properly acquired the art of managing this stage of labor. Gener- 
ally speaking, the placenta should be expelled within twenty minutes 

Fig. 108. 




Illustrating Expression of the Placenta. 

after the birth of the child, but no doubt in the large majority of cases 
expulsion might be effected sooner were it advisable to attempt i(. 

Management of the Membranes. — When the mass of the placenta is 
expelled, the membranes generally still remain in the vagina, and they 
should he twisted into a rope and very gently withdrawn, so as not 
to leave any portion behind. This is a precaution the importance of 
which I would strongly urge, for I believe that the chance of part of 
the membranes being torn off and left in litem is the one objection t<» 
the method recommended. With duo care, however, this accidenl may 
be avoided ; and the risk will be lessened if the placenta is received into 
the palm of the right hand, on expression, so as to avoid any strain on 
the membranes. 

Compression of the Uterus after the Expulsion of flic Placenta. — The 
duties of the medical attendant are qoI even dow over. For ;it !<';i-t 
ten minutes after the extrusion of the placenta he should keep his hand 
on the firmly-contracted uterus, gently kneading it, without any force, 
for the purpose of promoting firm and equable contraction and causing 
it to throw oil' the coagula that may form in its cavity. 



294 LABOR. 

Administration of Ergot of Rye. — The subsequent comfort and safety 
of the patient may be promoted by administering at this time a full dose 
of ergot of rye, such as a drachm or more of the liquid extract. The 
property possessed by this drug of producing tonic and persistent con- 
traction of the uterine fibres, which renders it of doubtful utility as an 
oxytocic during labor, is of special value after delivery, when such con- 
traction is precisely what we desire. I have long been in the habit of 
administering the drug at this period, and believe it to be of great value, 
not only as a prophylactic against hemorrhage, but as a means of lessen- 
ing after-pains. 

Application of the Binder. — When we are satisfied that the uterus is 
permanently contracted we may apply the binder, but this should rarely 
be done until at least half an hour after the birth of the child. The 
soiled clothes should be gently withdrawn from under the patient, mov- 
ing her as little as possible, and the binder should be, at the same time, 
slipped under the body, taking care that it is passed w T ell below the hips, 
so as to secure a firm hold. No kind of bandage is better than a piece 
of stout jean, of sufficient breadth to extend from the trochanters to 
the ensiform cartilage : a jack-towel or bolster slip answers the pur- 
pose very w r ell. These are preferable, at any rate at first, to the shaped 
binders that are often used. One or two folded napkins are gener- 
ally placed over the uterus, so as to form a pad to keep up pressure. 
Once in position, the binder is pulled tight and fastened by pins. The 
utility of careful bandaging after delivery can scarcely be doubted, 
although some years ago it became the fashion to dispense with it. It 
gives a comfortable support to the lax abdominal walls, keeps up a cer- 
tain amount of pressure on the uterus, and tends to restore the figure of 
the patient. After the bandage is applied a warm napkin should be 
placed on the vulva as a means of estimating the quantity of the dis- 
charge, and the patient may be allowed to rest. 

After- Treatment. — Unless the labor have been very long and fatiguing, 
an. opiate, often exhibited as a matter of routine, is unadvisable, although 
it may be well to leave one with the nurse, to be given if the patient 
cannot sleep or if the after-pains be very troublesome. The practitioner 
may now leave the room, but not the house, and at least an hour should 
elapse after delivery before he takes his departure. Before doing so he 
should visit the patient, inspect the napkin to see that there is not too 
much discharge, and satisfy himself that the uterus is contracted and 
not distended with coagula. He should also count the pulse, which, 
if the patient be progressing satisfactorily, will be found at its normal 
average. If, however, it be beating over 100 per minute, he should on 
no account leave, for such a rapidity of the circulation renders it 
extremely probable that hemorrhage is impending. This is a good 
practical rule, laid down by McClintock in his excellent paper " On 
the Pulse in Childbed," attention to which may often save the patient 
from disastrous consequences. 

Before leaving, the practitioner should see that the room is darkened, 
all bystanders excluded, and the patient left as quiet as possible to 
recover from the shock of labor. 



ANAESTHESIA IN LABOR. 295 



CHAPTEE IV. 

ANESTHESIA IN LABOR. 

A few words may be said as to the use of anaesthetics during labor — 
a practice which has become so universal that no argument is required 
to establish its being a perfectly legitimate means of assuaging the suf- 
ferings of childbirth. Indeed, the tendency in the present clay is in the 
opposite direction, and a common error is the administration of chloro- 
form to an extent which materially interferes with the uterine contrac- 
tions and predisposes to subsequent post-partum hemorrhage. 

Agents Employed. — Practically speaking, the only agent hitherto em- 
ployed in this country is chloroform, although the bichloride of methy- 
lene and ether have been occasionally tried. Of late years, chloral has 
been extensively used by some, and, as I believe it to be an agent of 
very great value, I shall first indicate the circumstances under which it 
may be employed. 

Chloral. — The peculiar value of chloral in labor is that it may be 
safely administered at a time when chloroform cannot be generally em- 
ployed. The latter, while it annuls suffering, very frequently tends in a 
marked degree to diminish uterine action. This is a familiar observation 
to all who have employed it much during labor, as the diminution of 
the force and intensity of the pains, and the consequent retardation of 
the labor, often oblige us to suspend its inhalation, at least temporarily. 
Indeed, this very property of annulling uterine action is one of its most 
valuable qualities in obstetrics, as in certain cases of turning. Pop such 
purposes it is necessary to give it to the surgical extent, which we 
endeavor to avoid when it is used simply to lessen the suffering of ordi-. 
nary labor. Still, it is not always easy to limit its action in this way, 
and thus it very frequently does more than we wish. Such diminution 
in the intensity of uterine contraction is comparatively of less conse- 
quence in the propulsive stage, and it is generally more than counter- 
balanced by the relief it affords. In the first stage it is otherwise, and, 
practically speaking, chloroform is generally not admissible until the 
head is in the pelvic cavity. 

Chloral is especially the Ancesthetic of the First Stage. — Chloral, on the 
other hand, has no such relaxing effects on uterine contraction. It cannot, 
it h true, compete with chloroform in its power of relieving pain, but it 
produces a drowsy state in which the pain is not felt nearly so acutely as 
before. It is therefore in the first stage of labor, while the pains are 
cutting and grinding, and during the dilatation of the cervix, that it finds 
its most useful application. It is especially valuable in those cases, so 
frequently met with in the upper classes, in which the pains produce 
intolerably acute suffering, but with little effect on the progress of the 
labor. In them the OS Is often thin and rigid and the pains very fre- 
quent and acute, but little or no dilatation is effected. When the patient 



296 LABOR. 

is brought under the influence of chloral, however, the pains become less 
frequent but stronger, nervous excitement is calmed, and the dilatation of 
the cervix often proceeds rapidly and satisfactorily. Indeed, I know of 
nothing which answers so well in cases of rigid, undilatable cervix, and 
I believe its administration to be far more effective, under such circum- 
stances, than any of the remedies usually employed. 

Object and Mode of Administration. — The object is to produce a som- 
nolent condition which shall be protracted as long as possible. For this 
purpose 15 grains of chloral may be administered every twenty minutes 
until three doses are given. This generally suffices to produce the 'de- 
sired effect. The patient becomes very drowsy, dozes between the pains, 
and wakes up as each contraction commences. It may be necessary to 
give a fourth dose at a longer interval, say an hour after the third dose, 
to keep up and prolong the soporific action ; but this is seldom necessary, 
and I have rarely given more than a drachm of chloral during the entire 
progress of labor. Another advantage of this treatment is that, while 
it does not interfere with the use of chloroform in the second stage, it 
renders it necessary to give less than otherwise would be called for, and 
thus its action can be more easily kept within bounds. On the whole, 
therefore, I am inclined to consider chloral a very valuable aid in the 
management of labor, and believe that it is destined to be much more 
extensively used than is at present the case. So far as my experience 
has yet gone, I have not met with any symptoms which have led me to 
think that it has produced bad effects ; and I have known many patients 
sleep quietly through labor, without expressing any excessive suffering 
or asking for chloroform > who under ordinary circumstances would have 
been most urgently calling for relief. It occasionally happens that the 
patient cannot retain the chloral from its tendency to produce sickness ; 
it may then be readily given per rectum in the form of enema. 

Chloroform. — Generally speaking, we do not think of giving chloro- 
form until the os is fully dilated, the head descending, and the pains 
becoming propulsive. It has often, indeed, been administered earlier, 
for the purpose of aiding the dilatation of a rigid cervix ; and there is 
no doubt that it often succeeds well when employed in this way, but I 
have already stated my belief that chloral answers this purpose better. 

Only to be Given during the Pains. — There is one cardinal rule to be 
remembered in giving chloroform during the propulsive stage, and that 
is that it should be administered intermittently, and never continuously. 
When the pain comes on a few drops may be scattered over a Skinner's 
inhaler, which affords one of the best means of administering it in labor, 
or placed within the folds of a handkerchief twisted into the form of a 
cone. During the acme of the pain the patient inhales it freely, and at 
once experiences a sense of great relief; and as soon as the pain dies 
away the inhaler should be removed. In the interval between the pains 
the effect of the drug passes off, so that the higher degree of anaesthesia 
should never be produced. Indeed, when properly given consciousness 
should not be entirely abolished, and the patient, between the pains, 
should be able to speak and understand what is said to her. This inter- 
mittent administration constitutes the peculiar safety of chloroform 
administered in labor ; and it is a fortunate circumstance that, as yet, 



ANAESTHESIA IN LABOR. 297 

there is, I believe, no case on record of death during the inhalation of 
chloroform for obstetric purposes. [*] This is obviously due to the effect 
of each inhalation passing off before a fresh dose is administered. 

The effect on the pains should be carefully watched. If they become 
very materially lessened in force and frequency, it may be necessary to 
stop the inhalation for a short time, commencing again when the pains 
get stronger ; which effect may be often completely and easily prevented 
by mixing the chloroform with about one-third of absolute alcohol, which, 
originally recommended, I believe, by Dr. Sansom, increases the stimu- 
lating effects of chloroform, and thus diminishes its tendency to produce 
undue relaxation. The amount administered must vary, of course, with 
the peculiarities of each individual case and the effect produced, but it 
need never be large. As the head distends the perineum and the pains 
get very strong and forcing, it may be given more freely, and to the 
extent of inducing even complete insensibility just before the child is 
born. 

Ether as a Substitute for Chloroform. — In cases in which chloroform 
has lessened the force of the pains ether may be given instead with great 
advantage. It certainly often acts well when chloroform is inadmissible 
on account of its effects on the pains, and, so far as my experience goes, 
it has not the property of relaxing the uterus, but, on the contrary, has 
sometimes seemed to me distinctly to intensify the pains. Of late I 
have used a mixture of one part of absolute alcohol, two of chloroform, 
and three of ether. This is less disagreeable than ether, and has not the 
over-relaxing effects of chloroform. 

Precautions. — Bearing in mind the tendency of chloroform to produce 
uterine relaxation, more than ordinary precautions should always be 
taken against posfc-partum hemorrhage in all cases in which it has been 
freely administered. 

In cases of operative midwifery it is often given to the extent of pro- 
ducing complete anaesthesia. In all such cases it should be administered, 
when possible, by another medical man, and not by the operator, because 
the giving of chloroform to the surgical degree requires the undivided 
attention of the administrator, and no man can do this and operate at 
the same time. I once learnt an important lesson on this point. 1 had 
occasion to apply the forceps in the case of a lady who insisted on hav- 
ing chloroform. When commencing the operation I noticed sonic sus- 
picious appearances about the patient, who was a large stout woman with 
a feeble circulation. I therefore stopped, allowed her to regain con- 
sciousness, and delivered her without anaesthesia, much to her own 
annoyance. Jusl on:' month alter labor she went to ,-i dentisi to have ;i 
tooth extracted, and took chloroform, during the inhalation of which she 
died. This impressed on my mind the lesson that no man can do two 
things at the same time. The partial unconsciousness of incomplete 
anaesthesia, in which the patient is restless and tossing about, renders 
the application of forceps, as well as all other operations, very difficult. 

f 1 In the Travsactions of the American Gynaecological Society for the year 1 v 77 are five 
cases of chloroform-poisoning occurring in obstetrical cases reported by I>r. W.T. Lnsk 
of New York. In three, restoration was effected by artificial respiration, but in two 
death resulted absolutely. — Ed.] 



298 LABOR. 

Therefore, unless the patient can be completely and fully anaesthetized, 
it is better to operate without chloroform being given at all. 

[In the United States the dangers attending the use of chloroform in 
obstetric practice have, in large measure, banished it from the lying-in 
chamber. Some obstetricians in our chief cities still resort to it with 
little hesitation, believing that by great carefulness in its administration, 
and by the substitution of ether in exceptional cases, all danger may be 
avoided. Others have a very great fear of it, and universally trust to 
the safer anaesthetic. It is an error to suppose that the parturient state 
robs chloroform of much of its danger, the apparent immunity being 
due to its intermittent and incomplete administration ; complete anaes- 
thesia being but a fraction less dangerous than in surgical operations 
upon women who are not pregnant. Dr. Lusk, already quoted, after a 
large experience with the use of chloroform, says : " Patients in labor do 
not enjoy any absolute immunity from the pernicious effects of chloroform" 1 
It is much to be regretted that this more pleasant anaesthetic is so much 
more dangerous than ether as an inhalant ; but in consideration of the 
difference of risk, that of their relative effects upon the nose and trachea 
is scarcely to be considered. Chloroform acts upon the respiratory cen- 
tres just as ether does ; and this is an element of danger in each, but is 
capable of being counteracted by artificial respiration. But, beyond this, 
chloroform is far more dangerous, in acting upon the motor ganglia of 
the heart and producing sudden death. According to the experiments 
of Vulpian upon animals, not more than one case of cardiac failure in 
forty can be restored by artificial respiration. He affirms that there is 
danger at the commencement, during the course, and at the close of 
chloroformization, and even some hours or days subsequent to it. ^ela- 
ton made the important discovery that the cerebral anaemia produced by 
chloroform, with its accompanying death-like condition, might be reme- 
died by long perseverance in artificial respiration with the patient turned 
head downward. 

Anaesthesia in labor is much less popular, both with obstetricians and 
patients in this country, than it was soon after its introduction. Improve- 
ments in the purity of sulphuric ether have made the narcosis more relia- 
ble, but the general effect upon patients varies very decidedly, being all 
that can be desired in some, and just the reverse in others. Some of the 
undesirable effects I have witnessed are intoxication, with cessation of 
labor, hysterical excitement, nightmare, and post-partum inertia and 
hemorrhage. I have also witnessed the most delightful results from 
ether that could be desired. In a small, delicate multipara, whose mother 
died of phthisis, and to whom I had been obliged to administer stimu- 
lants in the first and much of the second stage of labor, the use of ether 
had the effect to revolutionize her condition. Her pulse became strong ; 
her expulsive power increased ; she had no suffering : her placenta was 
expelled without accompanying blood ; and there was no subsequent ute- 
rine relaxation. But such cases are, unfortunately, exceptional. — Ed.] 

\} Opus cit] 



PELVIC PBESENTATIOXS. 299 



CHAPTER V. 

PELVIC PKESENTATIONS. 

Under the head of pelvic presentations it is customary to include all 
cases in which any part of the lower extremities of the child presents. 
By some these are further subdivided into breech, footling, and knee pres- 
entations ; but, although it is of consequence to be able to recognize the 
feet and the knee when they present, so far as the mechanism and man- 
agement of delivery are concerned- the cases are identical, and therefore 
may be most conveniently considered together. 

Frequency. — Presentations coming under this head are far from uncom- 
mon ; those in which the breech alone occupies the pelvis are met with, 
according to Churchill, once in 52 labors, while Pamsbotham estimates 
that it presents more frequently — viz. once in 38.8 labors. Footling 
presentations occur only once in 92 cases. They are probably often the 
mere conversion of original breech presentations, the feet having come 
down during the labor, either in consequence of the sudden escape of 
the liquor amnii when the breech w 7 as still freely movable above the 
brim, or from some other cause. Knee presentations are extremely rare, 
as may be readily understood if it be borne in mind that to admit them 
the thighs must be extended, hence the vertical measurement of the child 
must be greatly increased, and therefore it could not be readily accommo- 
dated within the uterine cavity unless of unusually small size. As a 
matter of fact, Mme. La Chapelle found only one knee presentation in 
upward of 3000 cases. 

Causes. — The causes of pelvic presentations are not known. They 
are probably the same as those which produce other varieties of mal- 
presentations ; and it is not unlikely that in certain women there may 
be some peculiarity in the shape of the uterine cavity which favors their 
production. It would be difficult otherwise to explain such a case as 
that mentioned by Velpeau in which the breech presented in six labors. 

Prognosis. — The results, as regards the mother, are in no way more 
unfavorable than in vertex presentation. The first stage of the labor is 
generally tedious, since the large rounded mass of the breech does not 
adapt itself so well as the head to the lower segment of the uterus, and 
dilatation of the cervix is consequently apt to be retarded. The second 
stage is, however, if anything, more rapid than in vertex cases ; and 
even when it is protracted tin; soft brceeh does not produce such injuri- 
ous pressure on the maternal structures as the hard and unyielding head. 

The Infantile Mortality in Pelvic Presentations. — The result is very 
different as regards the child. Dubois calculated that 1 out of 11 chil- 
dren was stillborn. Churchill estimates the mortality as much higher — 
viz. 1 in 3-|-. The latter certainly indicate- a larger number of stillbirths 
than is consistent with the experience <>(' most practitioners, and more 
than should occur if the cases be properly managed ; but there can be 



300 LABOR. 

no doubt that the risk to the child is, even under the most favorable 
circumstances, very great. Even when the child is not lost it may be 
seriously injured. Dr. Ruge has tabulated a series of 29 cases in which 
there were found to be fractures of bones or other injuries. 1 

Causes of Foetal Mortality. — The chief source of danger is pressure 
on the umbilical cord in the interval elapsing between the birth of the 
body and the head. At this time the cord is very generally compressed 
between the head of the child and the pelvic walls, so that circulation in 
its vessels is arrested. Hence the aeration of the foetal blood cannot 
take place, and, pulmonary respiration not having been yet established, 
the child dies asphyxiated. There are other conditions present which 
tend, although in a minor degree, to produce the same result. One of 
these is that the placenta is probably often separated by the uterine con- 
tractions when the bulk of the body is being expelled, as, indeed, takes 
place, under analogous circumstances, when the vertex presents, the 
necessary result being the arrest of placental respiration. Joulin thinks 
that the same eifect may be produced by the compression of the placenta 
between the contracted uterus and the hard mass of the fcetal skull. 
Probably all these causes combine to arrest the functions of the placenta, 
and if the delivery of the head, and consequently the establishment of 
pulmonary respiration, be delayed, the death of the child is almost 
inevitable. The corollary is, that the danger to the child is in direct 
proportion to the length of time that elapses between the birth of the 
body and that of the head. 

The risk to the child is greater in footling than in breech cases, 
because in the former the maternal structures are less perfectly dila- 
ted in consequence of the small size of the feet and thighs, and there- 
fore the birth of the head is more apt to be delayed. 

Diagnosis. — Inasmuch as the long axis of the child corresponds with 
the long axis of the uterus in pelvic as in vertex presentations, there is 
nothing in the shape of the uterus to arouse suspicion as to the character 
of the case. Still, it is often sufficiently easy to recognize a pelvic pres- 
entation by abdominal examination if we have occasion to make one. 
The facility with which it may be done depends a good deal on the 
individual patient. If she be not very stout, and if the abdominal 
parietes be lax and non-resistant, w T e shall generally be able to feel the 
round head at the upper part of the uterus, much firmer and more 
defined in outline than the breech. The conclusion will be fortified if 
we hear the foetal heart beating on a level with or above the umbilicus. 
The greater resistance on one side of the abdomen will also enable us to 
decide with tolerable accuracy to which side the back of the child is 
placed. Information thus acquired is, at the best, uncertain, and we 
can never be quite sure of the existence of a pelvic presentation until we 
can corroborate the diagnosis by vaginal examination. 

Results of Vaginal Examination. — The first circumstance to excite 
suspicion on examination per vaginam, even when the os is undilated, is 
the absence of the hard globular mass felt through the lower segment of 
the uterus, so characteristic of vertex presentations. When the os is 
sufficiently open to allow the membranes to protrude, although the pre- 

1 Bull. gen. de Therap., August, 1875. 



PELVIC PRESENTATIONS. 301 

senting part is too high up to be within reach, we may be struck with 
the j)eculiar shape of the bag of membranes, which, instead of being 
rounded, projects a considerable distance through the os, like the ringer 
of a glove. This is a peculiarity met with in all mal-presentations 
alike, and is, indeed, much less distinct in breech than in footling pres- 
entations, because in the former the membranes are more stretched, 
just as they are in vertex cases. When the membranes rupture, instead 
of the waters dribbling away by degrees, they often escape with a rush, 
in consequence of the pelvic extremity not filling up the lower part of 
the uterus so accurately as the head, which acts as a sort of ball-valve 
and prevents the sudden and complete discharge of the waters. 

Diagnosis of the Breech. — Often, on first examining, even when the 
membranes are ruptured, the presentation is too high up to be made 
out accurately. All that we can be certain of is that it is not the head ; 
and the case must be carefully watched and examinations frequently 
repeated until the precise nature of the presentation can be established. 
If the breech present, the finger first impinges on a round, soft prom- 
inence, on depressing which a bony protuberance, the trochanter major, 
can be felt. On passing the finger upward it reaches a groove, beyond 
which a similar fleshy mass, the other buttock, can be felt. In this 
groove various characteristic points, diagnostic of the presentation, can 
be made out. Toward one end we can feel the movable tip of the 
coccyx, and above it the hard sacrum with its rough projecting prom- 
inences. These points, if accurately made out, are quite characteristic, 
and resemble nothing in any other presentation. In front there is the 
anus, in which it is sometimes, but by no means always, possible to 
insert the tip of the finger. If this can be done, it is easy to distinguish 
it from the mouth, with which it might be confounded, by observing 
that the hard alveolar ridges are not contained within it. Still more in 
front we may find the genital organs, the scrotum in male children 
being often much swollen if the labor has been protracted. Thus it is 
often possible to recognize the sex of the child before birth. 

Differential Diagnosis, — The breech might be mistaken for the face, 
especially if the latter be much swollen; but this mistake can readily be 
avoided by feeling the spinous processes of the sacrum. 

The knee [g recognized by its having two tuberosities with a depres- 
sion between them. It might be confounded with the heel, the elbow, 
or the shoulder. From the heel it is distinguished by having two 
tuberosities instead of one; from the elbow, by the latter having one 

sharp tuberosity, with a depression on one side, instead of a central 

depression and two lateral prominences; and from the shoulder, by the 

latter being more rounded, having only one prominence, running from 
which the acromion and clavicle can be traced. 

Diagnosis of the Fool. — The foot may be mistaken for the band. 
This error will be avoided by remembering that all the toes are in the 
same line, and that the great toe cannot be brought into apposition with 
the other-, as the thumb can with the fingers. The internal border of 
the foot is much thicker than the external, whereas the two borders of 
the hand are of the same thickness. Moreover, the foot is articulated 
at right angles to the leg, and cannot be brought into a line with it, as 



302 LABOR. 

the hand can with the arm. Finally, the projection of the calcaneum is 
characteristic, and resembles nothing in the hand. 

Mechanism. — As is the case in other presentations, obstetricians have 
very variously subdivided breech presentations, with the effect of need- 
lessly complicating the subject. The simplest division, and that which 
will most readily impress itself on the memory of the student, is to 
describe the breech as presenting in four positions, analogous to those of 
the vertex, the sacrum being taken as representing the occiput, and the 
positions being numbered according to the part of the pelvis to which 
it points. Thus we have — 

First, or left sacro-anterior (corresponding to the first position of the 
vertex). The sacrum of the child points to the left foramen ovale of 
the mother. 

Second, or right sacro-anterior (corresponding to the second vertex 
position). The sacrum of the child points to the right foramen ovale 
of the mother. 

Third, or right sacroposterior (corresponding to the third vertex 
position). The sacrum of the child points to the right sacro-iliac 
synchondrosis of the mother. 

Fourth, or left sacro-posterior (corresponding to the fourth vertex 
position). The sacrum of the child points to the left sacro-iliac 
synchondrosis of the mother, 

Of these, as with the corresponding vertex positions, the first and 
third are the most common, their comparative frequency, no doubt, 
depending on the same causes. The mechanical conditions to which the 
presenting part is subjected are also identical, but the alterations of posi- 
tion of the breech in its progress are by no means so uniform as those 
of the head, on account of its less perfect adaptation to the pelvic cavity. 
The mechanism of the delivery of the shoulders and head in breech 
presentations, moreover, is of much greater practical importance than 
that of the body in vertex presentations, inasmuch as the safety of the 
child depends on its speedy and satisfactory accomplishment. Bearing 
these facts in mind, it will suffice to describe briefly the phenomena of 
delivery in the first and third breech positions. 

Position of the Child at Brim. — In the first position (Fig. 109) the 
sacrum of the child points to the left foramen ovale ; its back is conse- 
quently placed to the left side of the uterus and anteriorly, and its abdo- 
men looks to the right side of the uterus and posteriorly. The sulcus 
between the buttocks lies in the right oblique diameter of the pelvis, 
while the transverse diameter of the buttocks lies in the left oblique 
diameter, the left buttock being most easily within reach. As in vertex 
presentations, the hips of the child lie on the same level at the pelvic 
brim, although Naegele describes the left hip as placed lower than the 
right. 

Descent. — As the pains act on the body of the child the breech is 
gradually forced through the pelvic cavity, retaining the same relations 
as at the brim, its progress being generally more slow than that of the 
head, until it reaches the lower pelvic strait, when the same mechanism 
which produces rotation of the occiput comes to operate upon it. The 
result is a rotation of the child's pelvis, so that its transverse diameter 



PELVIC PRESENTATIONS. 



303 



comes to lie approximately in the antero-posterior diameter of the out- 
let ; its antero-posterior diameter corresponds to the transverse diameter 
of the mother's pelvis, the left hip lies behind the pubes, and the right 
toward the sacrum. This rotation, which is admitted by the majority 
of obstetricians, is altogether denied by Xaegele. There can be no 
doubt, however, that it does generally take place, but by no means so 
constantly as the corresponding rotation of the vertex ; and it is not 
uncommon for it to be entirely absent and for the hips to be born in the 
oblique diameter of the outlet. The body of the child is said frequently 
not to follow the movement imparted to the hips, so that there is more 
or less of a twist in the vertebral column. 

Expulsion of the Hips and Body. — The left hip now becomes firmly 
fixed behind the pubes, and a movement of extension, analogous to that 



Fig. 109. 




First, or Left Saero-anterior, Position of the Breech. 

of the head in vertex presentations, takes place. The right, or posterior, 
hip revolves round the fixed one, gradually distends the perineum, and 
is expelled first, the left hip rapidly following. As soon as both hips 
are born t\\i\ feet slip out, unless the legs are completely extended upon 
the child's abdomen. The shoulders soon follow, lying in the left oblique 
diameter of the pelvis (Fig. 110). The left shoulder rotates forward 
behind the pnbes, where it becomes fixed, the right shoulder sweeping 
over the perineum and being born first. The arms of the child are 
generally found placed upon its thorax, and are born before the shoulders. 
Sometimes they are extended over the child's head, thus causing consid- 
erable delay and greatly increasing the risk to the child. It is now gen- 
erally admitted that such extension is most apt to occur when traction 
has been made on the child's body with the view of hastening delivery, 
and that it is rarely met with when the expulsion of the body is left 
entirely to the natural powers. 



304 



LABOR. 



Delivery of the Head. — When the shoulders are expelled the head 
enters the pelvis in the opposite, or right oblique, diameter, the face 
looking to the right sacro-iliac synchondrosis. As the greater part of 



Fig. 110. 




Passage of the Shoulders and Partial Rotation of the Thorax. 

the child is now expelled, and as the head has entered the vagina, the 
uterus, having a comparatively small mass to contract upon, must obvi- 
ously act at a mechanical disadvantage. Still, the pressure of the head 
on the vagina is a powerful inciter, the accessory muscles of parturition 
are brought into strong action, and there may be sufficient force to ensure 
expulsion of the head without artificial aid. On account of the great 
resistance to the descent of the occiput from its articulation with the 
spinal column, the pains have the effect of forcing down the anterior 
portion of the head, and this ensures the complete flexion of the chin 
upon the sternum (Fig. 111). This is a great advantage from a mechan- 
ical point of view, as it causes the short occipito-mental diameter of the 

Fig. 111. 




Descent of the Head. 



head to enter the pelvis in the axis of the uterus and the brim. If the 
head should be in a state of partial extension, as sometimes happens 
when the pelvis is unusually roomy, the occipitofrontal diameter is 



PELVIC PRESENTATION'S. 305 

placed in a similar relation to the brim — a position certainly less favor- 
able to the easy birth of the head. As the head descends it experiences 
a movement of rotation, the occiput passing forward and to the right, 
behind the pubic arch, the face turning backward into the hollow of the 
sacrum. The body of the child will be observed to follow this move- 
ment, so that its back is turned toward the mother's abdomen, its ante- 
rior surface to the perineum. The nape of the neck now becomes firmly 
fixed under the arch of the pubes ; the pains act chiefly on the anterior 
portion of the head, and cause it to sweep over the perineum, the 
chin being: first born, then the mouth and forehead, and lastly the 
occiput. 

Sacro-posterior Positions. — It is needless to describe the differences 
between the mechanism of the second and first positions, which the stu- 
dent, who has mastered the subject of vertex presentations, will readily 
understand. It is necessary, however, to say a few words as to sacro- 
posterior positions, choosing for that purpose the third, which is the more 
common of the two. This is exactly the opposite of the first position. 
The sacrum of the child points to the right sacro-iliac synchondrosis ; its 
abdomen looks forward and to the left side of the mother. The trans- 
verse diameter of the child's pelvis lies in the left oblique diameter, the 
right hip being anterior. The birth of the body generally takes place 
exactly in the way that has been already described, the right hip being 
toward the pubes. 

As the head descends into the pelvis the occiput most usually rotates 
along its right side — the rotation having been often already partially 
eifected when that of the hips had been made — until it comes to rest 
behind the pubes, the face passing backward along the left side of the 
pelvis into the hollow of the sacrum. This change corresponds exactly 
to the anterior rotation of the occiput in occipito-posterior positions, and 
is the natural and favorable termination. 

Sometimes, forward rotation does not take place, and the occiput then 
turns backward into the hollow of the sacrum. What then generally 
occur- is, that the pains continue, for the reason already mentioned, to 
depress the chin and produce strong flexion of the face on the sternum, 
the occiput becoming fixed on the anterior border of the perineum. The 
pains continuing to act chiefly on the anterior part of the head, the face 
is born first behind the pubes, the occiput only slipping over the per- 
ineum after the forehead has been expelled. 

Second Mode iii which such Cases occasionally End. — A second mode 
of termination of such positions is mentioned in most works on the 
authority of one or two recorded cases ; but, although mechanically 
possible, it is certainly an event of extreme rarity. The chin, Instead 
of being flexed on the sternum, is greatly extended, so that the face of 
the child looks upward toward the pelvic brim. The child then 
hitches over the upper edge of the pubes, and becomes fixed there, while 

the force of the uterine contractions is expended on the posterior pari of 
the head, which descend- through the pelvis, distending the perineum, 
and is born first, the face subsequently following. 

Mechanism of Feet Presentations. — The mechanism of the delivery 

of the body and head in cases in which the feet originally present does 

20 



306 LABOR. 

not differ, in any important respect, from that which has been already 
described, and requires no separate notice. 

Treatment. — From what has been said of the natural mechanism, it is 
evident that one of the most fruitful causes of difficulty and complication 
is undue interference on the part of the practitioner. It is, no doubt, 
tempting to use traction on the partially-born trunk in the hope of 
expediting delivery, but when it is remembered that this is almost 
certain to produce extension of the arms above the head, and subse- 
quently extension of the occiput on the spine, both of which seriously 
increase the difficulty of delivery, the necessity of leaving the case as 
much as possible to nature will be apparent. 

Having once, therefore, determined the existence of a pelvic presenta- 
tion, nothing more should be done until the birth of the breech. The 
membranes should be even more carefully prevented from prematurely 
rupturing than in vertex presentations, since they serve to dilate the 
genital passages better than the presenting part. Hence they should be 
preserved intact, if possible, until they reach the floor of the pelvis, 
instead of being punctured as soon as the os is fully dilated. The 
breech when born should be received and supported in the palm of the 
hand. 

Danger to Child. — When the body is expelled as far as the umbilicus 
the dangers to the child commence, for now the cord is apt to be pressed 
between the body of the child and the pelvic walls. To obviate this 
risk as much as possible, a loop of the cord should be pulled down and 
carried to that part of the pelvis where there is most room, which will 
generally be opposite one or the other sacro-iliac synchondrosis. As long 
as the cord is freely pulsating we may be satisfied that the life of the 
child is not gravely imperilled, although delay is fraught with danger 
from other sources which have been already indicated. In most cases 
the arms now slip out, but it may happen, even without any fault on the 
part of the accoucheur, that they are extended above the head ; and it is 
of great importance that we should be thoroughly acquainted with the 
best means of liberating them from their abnormal position. 

Management when the Arms are Extended above the Head. — They must, 
of course, never be drawn directly downward, or the almost certain result 
would be fracture of the fragile bones. We should endeavor to make 
the arm sweep over the face and chest of the child, so that the natural 
movements of its joints should not be opposed. If the shoulders be 
within easy reach, the finger of the accoucheur should be slipped over 
that which is posterior — because there is likely to be more space for this 
manoeuvre toward the sacrum — and gently carried downward toward 
the elbow, which is drawn over the face, and then onward, so as to 
liberate the forearm. The same manoeuvre should then be applied to 
the opposite arm. It may be that the shoulders are not easily reached, 
and then they may be depressed by altering the position of the child's 
body. If this be carried well up to the mother's abdomen, the posterior 
shoulder will be brought lower down ; and, by reversing this procedure 
and carrying the body back over the perineum, the anterior shoulder 
may be similarly depressed. It is only very exceptionally, however, 
that these expedients are required. 



PELVIC PBESEXTATIOXS. 307 

Birth of the Head. — The arms being extracted, some degree of artifi- 
cial assistance is at this time almost always required. If there be much 
delay the child will almost certainly perish. Attempts have been made, 
in cases in which delivery of the head could not be rapidly effected, to 
establish pulmonary respiration by passing one or two fingers into the 
vagina, so as to press it back and admit air to the child's mouth, or by 
passing a catheter or tube into the mouth. Xeither of these expedients 
is reliable, and we should rather seek to aid nature in completing the 
birth of the head as rapidly as possible. The first thing to do, supposing 
the face to have rotated into the cavity of the sacrum, is to carry the 
body of the child well up toward the pubes and abdomen of the mother 
without applying any traction, for fear of interfering with the all- 
important flexion of the chin on the sternum. If now the patient bear 
down strongly, the natural powers may be sufficient to complete delivery. 
If there be any delay, traction must be resorted to, and we must endeavor 
to apply it in such way as to ensure flexion. For this purpose, while 
the body of the child is grasped by the left hand and drawn upward 
toward the mother's abdomen, the index and middle fingers of the right 
hand are placed on the back of the child's neck, so that their tips press 
on either side of the base of the occiput and push the head into a state 
of flexion. In most works we are advised to pass the index and middle 
fingers of the left hand at the same time over the child's face, so as to 
depress the superior maxilla. Dr. Barnes insists that this is quite 
unnecessary, and that extraction in the manner indicated, by pressure 
on the occiput, is quite sufficient. Should it not prove so, flexion of the 
chin may be very effectually assisted by downward pressure on the fore- 
head through the rectum. One or two fingers of the left hand can 
readily be inserted into the bowel, and the expulsion of the head is thus 
materially facilitated. 

Value of Pressure through the Abdomen. — By far the most powerful 
aid, however, in hastening delivery of the head, should delay occur, is 
pressure from above. This has been, strangely enough, almost altogether 
omitted by writers on the subject. It has been strongly recommended 
by Professor Penrose, and there can be no question of its utility. Indeed, 
as the uterus contracts tightly round the head, uterine expression can be 
applied almost directly to the head itself, and without any fear of 
deranging its proper relation to the maternal passages. It is very 
seldom, indeed, that a judicious combination of traction on the part of 
the accoucheur, with firm pressure through the abdomen applied by an 
assistant, will fail in effecting delivery of the head before the delay lias 
had time-to prove injurious to the child. 

Application of the Forceps to the After-coming Head. — Many accou- 
cheurs — among others Meigs and Rigbv — advocate the application of 
tiie forceps when there is delay in the birth of the after-coming head. 
If the delay be due to want of expulsive force in a pelvis of normal si/e, 
manual extraction, in the manner just described, will be found to he 
sufficient in almost every case, and preferable, as being more rapid, 
easier of execution, and safer to the child. The forceps may be quite 
properly tried if other means have failed, especially it' there be some 
disproportion between the size of the head and the pelvis. 



308 LABOR. 

Management of Sacro-posterior Positions. — Difficulties in delivery may 
also occur in sacro-posterior positions. Up to the time of the birth of 
the head the labor usually progresses as readily as in sacro-anterior posi- 
tions. If the forward rotation of the hips do not take place, much 
subsequent difficulty may be prevented by gently favoring it by traction 
applied to the breech during the pains, the finger being passed for this 
purpose into the fold of the groin. 

It is after the birth of the shoulders that the absence of rotation is 
most likely to prove troublesome. It has been recommended that the 
body should then be grasped, in the interval between the pains, and 
twisted round so as to bring the occiput forward. It is by no means 
certain, however, that the head would follow the movement imparted to 
the body, and there must be a serious danger of giving a fatal twist of 
the neck by such a manoeuvre. The better plan is to direct the face 
backward toward the cavity of the sacrum, by pressing on the anterior 
temple during the continuance of a pain. In this way the proper rota- 
tion will generally be effected without much difficulty, and the case will 
terminate in the usual way. 

Management of Cases in which Forward Rotation does not Occur. — If 
rotation of the occiput forward do not occur, it is necessary for the prac- 
titioner to bear in mind the natural mechanism of delivery under such 
circumstances. In the majority of cases the proper plan is to favor 
flexion of the chin by upward pressure on the occiput, and to exert trac- 
tion directly backward, remembering that the nape of the neck should 
be fixed against the anterior margin of the perineum. If this be not 
remembered, and traction be made in the axis of the pelvic outlet, the 
delivery of the head will be seriously impeded. In the rare cases in 
which the head becomes extended and the chin hitches on the upper 
margin of the pubis, traction directly forward and upward may be 
required to deliver the head ; but before resorting to it care should be 
taken to ascertain that backward extension of the head has really taken 
place. 

Management of Impacted Breech Presentations. — It remains for us to 
consider the measures which may be adopted in those very troublesome 
cases in which the breech refuses to descend and becomes impacted in 
the pelvic cavity, either from uterine inertia or from disproportion 
between the breech and the pelvis. Here, unfortunately, the peculiar 
shape of the presenting part, which is unadapted for the application of 
the forceps, renders such cases very difficult to manage. 

Two measures have been chiefly employed ; 1st, bringing down one 
or both feet, so as to break up the presenting part and convert it into a 
footling case ; 2d, traction on the breech, either by the fingers, a blunt 
hook, or fillet passed over the groin. 

Bringing Down a Foot. — Barnes insists on the superiority of the 
former plan, and there can be no question that, if a foot can be got 
down, the accoucheur has a complete control over the progress of the 
labor which he can gain in no other way. If the breech be arrested at 
or near the brim, there will generally be no great difficulty in effecting 
the desired object. It will be necessary to give chloroform to the extent 
of complete anaesthesia, and to pass the hand over the child's abdomen 



PELVIC PRESENTATIONS. 309 

in the same manner and with the same precautions as in performing 
podalic version until a foot is reached, which is seized and pulled down. 
If the feet be placed in the usual way close to the buttocks, no great 
difficulty is likely to be experienced. If, however, the legs be extended 
on the abdomen, it will be necessary to introduce the hand and arm very 
deeply, even up to the fundus of the uterus — a procedure which is 
always difficult, and which may be very hazardous. Xor do I think 
that the attempt to bring down the feet can be safe when the breech is 
low down and fixed in the pelvic cavity. A certain amount of repres- 
sion of the breech is possible, but it is evident that this cannot be safely 
attempted when the breech is at all low down. 

Traction on the Groin. — Under such circumstances traction is our 
only resource, and this is always difficult and often unsatisfactory. Of 
all contrivances for this purpose, none is better than the hand of the 
accoucheur. The index finger can generally be slipped over the groin 
without difficulty, and traction can be applied during the pains. Fail- 
ing this or when it proves insufficient, an attempt should be made to 
pass a fillet over the groins. A soft silk handkerchief or a skein of 
worsted answers best, but it is by no means easy to apply. The sim- 
plest plan, and one which is far better than the expensive instruments 
contrived for the purpose, is to take a stout piece of copper wire and 
bend it double into the form of a hook. The extremity of this can gen- 
erally be guided over the hips, and through its looped end the fillet is 
passed. The wire is now withdrawn, and carries the fillet over the 
groins. I have found this simple contrivance, which can be manufac- 
tured in a few moments, very useful, and by means of such a fillet very 
considerable tractive force can be employed. The use of a soft fillet is 
in every way preferable to the blunt hook which is contained in most 
obstetric bags. A hard instrument of this kind is quite as difficult to 
apply, and any strong traction employed by it is almost certain to seri- 
ously injure the delicate foetal structures over which it is placed. As 
an auxiliary the employment of uterine expression should not be forgot- 
ten, since it may give material aid when the difficulty is only due to 
uterine inertia. After a difficult breech labor is completed the child 
should be carefully examined to see that the bones of the thighs and 
arms have not been injured. Fractures of the thigh are far from uncom- 
mon in such cases, and the soft bones of the newly-born child will read- 
ily and rapidly unite if placed at once in proper splints. 

Embryotomy. — Failing all endeavors to deliver by these expedients, 
there is no resource left but to break up the presenting part by scissors 
or by craniotomy instruments; but, fortunately, so extreme a measure 
is but rarely necessary. 



310 LABOR. 



CHAPTER VI. 

PKESENTATIONS OF THE FACE. 

Presentations of the face are by no means rare, and, although in 
the great majority of cases they terminate satisfactorily by the unassisted 
powers of nature, yet every now and again they give rise to much diffi- 
culty, and then they may be justly said to be amongst the most formid- 
able of obstetric complications. It is therefore essential that the prac- 
titioner should thoroughly understand the natural history of this variety 
of presentation, with the view of enabling him to intervene with the 
best prospect of success. 

Erroneous Views Formerly Held. — The older accoucheurs had very 
erroneous views as to the mechanism and treatment of these cases, most 
of them believing that delivery was impossible by the natural efforts, 
and that it was necessary to intervene by version in order to effect deliv- 
ery. Smellie recognized the fact that spontaneous delivery is possible, 
and that the chin turns forward and under the pubes ; but it was not 
until long after his time, and chiefly after the appearance of Mine. La 
Chapelle's essay on the subject, that the fact that most cases could be 
naturally delivered was fully admitted and acted upon. 

Frequency. — The frequency of face presentation varies curiously in 
different countries. Thus, Collins found that in the Rotunda Hospital 
there was only 1 case in 497 labors, although Churchill gives 1 in 249 
as the average frequency in British practice ; while in Germany this 
presentation is met with once in 169 labors. The only reasonable 
explanation of this remarkable difference is, that the dorsal decubitus, 
generally followed abroad, favors the transformation of vertex presenta- 
tions into those of the face. 

The mode in which this change is effected — for it can hardly be 
doubted that in the large majority of cases face presentation is clue to a 
backward displacement of the occiput after labor has actually com- 
menced, but before the head has engaged in the brim — has been made 
the subject of various explanations. 

Mode in which Face Presentations are Produced. — It has generally been 
supposed that the change is induced by a hitching of the occiput on the 
brim of the pelvis, so as to produce extension of the head and descent 
of the face, the occurrence being favored by the oblique position of the 
uterus so frequently met with in pregnancy. Hecker attaches consider- 
able importance to a peculiarity in the shape of the foetal head generally 
observed in face presentations, the cranium having the dolicho-cephalous 
form, prominent posteriorly, with the occiput projecting, which has the 
effect of increasing the length of the posterior cranial lever arm, and 
facilitating extension when circumstances favoring it are in action. Dr. 
Duncan l thinks that uterine obliquity has much influence in the produc- 
tion of face presentation, but in a different way to that above referred 

1 Edin. Med. Journ., vol. xv. 



PRESENTATIONS OF THE FACE. 311 

to. He points out that when obliquity is very marked a curve in the 
genital passages is produced, the convexity of which is directed to the 
side toward which the uterus is deflected. When uterine contraction 
commences the foetus is propelled downward, and the part corresponding 
to the concavity of the curve is acted on to the greatest advantage by the 
propelling force, and tends to descend. Should the occiput happen to 
lie in the convexity of the curve so formed, the tendency will be for the 
forehead to descend. In the majority of cases its descent will be pre- 
vented by the increased resistance it meets with, in consequence of the 
greater length of the anterior cranial lever arm ; but if the uterine 
obliquity be extreme this may be counterbalanced, and a face presenta- 
tion ensues. The influence of this obliquity is corroborated by the 
observation of Baudelocque, that the occiput in face presentations almost 
invariably corresponds to the side of the uterine obliquity. A further 
corroboration is afforded by the fact that in face presentation the occiput 
is much more frequently directed to the right than to the left, while right 
lateral obliquity of the uterus is also much more common. 

These theories assume that face presentations are produced during 
labor. In a few cases they certainly exist before labor has commenced. 
It is possible, however, as we know that uterine contractions exist inde- 
pendently of actual labor, that similar causes may also be in operation, 
although less distinctly, before the commencement of labor. 

Diar/aosls. — The diagnosis is often a matter of considerable difficulty 
at an early period of labor, before the os is fully dilated and the mem- 
branes ruptured, and when the face has not entered the pelvic cavity. 
The finger then impinges on the rounded mass of the forehead, which 
may very readily be mistaken for the vertex. At this stage the diag- 
nosis may be facilitated by abdominal palpation in the way suggested by 
Hecker. If the face is presenting at the brim, palpation will enable us 
to distinguish a hard, firm, and rounded body immediately above the 
pubes, which is the forehead and sinciput ; on the other side will be felt 
an indistinct, soft substance, corresponding to the thorax and neck. 
When labor is advanced and the head has somewhat descended, or when 
the membranes are ruptured, we should be able to make out the nature 
of the presentation with certainty. The diagnostic marks to be relied 
on are the edges of the orbits, the prominence of the nose, the nostrils 
(their orifices showing to which part of the pelvis the chin is turned), 
and the cavity of the mouth with the alveolar ridges. If these be made 
out satisfactorily, no mistake should occur. The mosl difficult cases are 
til)-' in which the face has been a considerable time in the pelvis. 
Under such circumstance- the cheeks become greatly swollen and pressed 
together, so as to resemble the nates. The nose might then be mistaken 
for the genital organs, and the mouth for the ami-. The orbits, how- 
ever, and the alveolar ridges resemble nothing in the breech, and should 
be sufficient to prevent error. Considerable care should be taken not to 
examine too frequently and roughly, otherwise serious injury to the deli- 
cate structures of the lace might be indicted. When once the presenta- 
tion has been satisfactorily diagnosed, examination- should be made as 
seldom as possible, and only to assure ourselves that the case is progress- 
ing satisfactorily. 



312 LABOR. 

Mechanism. — If we regard face presentations, as we are fully justified 
in doing, as being generally produced by the extension of the occiput in 
what were originally vertex presentations, w T e can readily understand 
that the position of the face in relation to the pelvis must correspond 
to that of the vertex. This is, in fact, what is found to be the case, the 
forehead occupying the position in which the occiput would have been 
placed had extension not occurred. 

The Positions of the Face correspond to those of the Vertex. — The face, 
then, like the head, may be placed with its long diameter corresponding 
to almost any of the diameters of the brim, but most generally it lies 
either in the transverse diameter or between this and the oblique, while, 
as it descends in the pelvis, it more generally occupies one or other of 
the oblique diameters. It is common in obstetric works to describe two 
principal varieties of face presentation — viz. the right and left mento- 
iliac — according as the chin is turned to one or other side of the pelvis. 
It is better, however, to classify the positions in accordance with the part 
of the pelvis to which the chin points. We may therefore describe four 
positions of the face, each being analogous to one of the ordinary vertex 
presentations, of which it is the transformation : 

First Position. — The chin points to the right sacro-iliac synchondro- 
sis, the forehead to the left foramen ovale, and the long diameter of the 
face lies in the right oblique diameter of the pelvis. This corresponds 
to the first position of the vertex, and, as in that, the back of the child 
lies to the left side of the mother. 

Second Position. — The chin points to the left sacro-iliac synchondro- 
sis, the forehead to the right foramen ovale, and the long diameter of 
the face lies in the left oblique diameter of the pelvis. This is the con- 
version of the second vertex position. 

Third Position. — The forehead (Fig. 112) points to the right sacro- 
iliac synchondrosis, the chin to the left foramen ovale, and the long 
diameter of the face lies in the right oblique diameter of the pelvis. 
This is the conversion of the third vertex position. 

Fourth Position. — The forehead points to the left sacro-iliac synchon- 
drosis, the chin to the right foramen ovale, and the long diameter of the 
face lies in the left oblique diameter of the pelvis. This is the conver- 
sion of the fourth vertex position. 

The Relative Frequency of these Positions. — The relative frequency of 
these presentations is not yet positively ascertained. It is certain that 
there is not the preponderance of first facial that there is of first vertex 
positions, and this may no doubt be explained by the supposition that 
an unusual vertex position may of itself facilitate the transformation 
into a face presentation. Winckel concludes that, eazteris paribus, a face 
presentation is more readily produced when the back of the child lies to 
the right than when it lies to the left side of the mother, the reason for 
this being probably the frequency of right lateral obliquity of the uterus. 
We shall presently see that, with very rare exceptions, it is absolutely 
essential that the chin should rotate forward under the pubes before 
delivery can be accomplished ; and therefore we may regard the third 
and fourth face positions, in which the chin from the first points ante- 
riorly, as more favorable than the first and second. 



PRESENTATIONS OF THE FACE. 



313 



The mechanism of delivery in face is practically the same as in vertex 
presentations ; and we shall have no difficulty in understanding it if we 
bear in mind that in face cases the forehead takes the place of, and rep- 
resents the occiput in, vertex presentations. For the purpose of descrip- 
tion we will take the first position of the face. 

Description of Delivery in the First Position of the Face. — 1. Exten- 
sion. — The first step consists in the extension of the head, which is 
effected by the uterine contractions as soon as the membranes are rup- 
tured. By this the occiput is still more completely pressed back on the 
nape of the neck, and the fronto-mental, rather than the mento-breg- 

Fig. 112. 




Third Position in Face Presentations. 



matic, diameter is placed in relation to the pelvic brim. This corre- 
sponds to the stage of flexion in vertex presentations. 

The chin descends below the forehead from precisely the same cause 
as the occiput in vertex presentation-. On account of the extended posi- 
tion of the head the presenting face is divided into portions of unequal 
length in relation to the vertebral column, through which the force is ap- 
plied, the longer lever arm being toward the forehead. The resistance 
is, therefore, greatest toward the forehead, which remains behind while 
the chin descends. 

2. Descent. — As the pains continue, the head (the chin being still iu 
advance) is propelled through the pelvis. It is generally said that the 
face cannot descend, like the occiput, down to the floor of the pelvis, 
its descent being limited by the length of the neck. There IS here, 
however, an obvious misapprehension. The neck from the chin to the 
Sternum, when the head is forcibly extended, measures from 3^ to 1 
inches — a length that is more than sufficient to admit of the face descend- 
ing to the lower pelvic strait. As a matter of fact, the chin is frequently 
observed in mento-posterior positions to descend so far that it is appar- 



314 



LABOR. 



ently endeavoring to pass the perineum before rotation occurs. At the 
brim the two sides of the face are on a level, but as labor advances the 
right cheek descends somewhat, the caput succedaneum forms on the 
malar bone, and, if a secondary caput succedaneum form, on the cheek. 

3. Rotation is by far the most important point in the mechanism of 
face presentations ; for unless it occurs, delivery with a full-sized head 
and an average pelvis is practically impossible. There are, no doubt, 
exceptions to this rule, which must be separately considered, but it is 
certain that the absence of rotation is always a grave and formidable 
complication of face presentation. Fortunately, it is only very rarely 
that this is not effected. The mechanical causes are precisely those which 
produce rotation of the occiput forward in vertex presentations. As it 
is accomplished the chin passes under the arch of the pubes, and the 
occiput rotates into the hollow of the sacrum (Fig. 113); and then 
commences — 

4. Flexion, a movement which corresponds to extension in vertex 
cases. The chin passes as far as it can under the pubic arch, and there 

Fig. 113. 




Rotation Forward of Chin. 

becomes fixed. The uterine force is now expended on the occiput, which 
revolves, as it were, on its transverse axis (Fig. 114), the under surface 
of the chin resting on the pubes as a fixed point. This movement goes 
on until, at last, the face and occiput sweep over the distended perineum. 

5. External rotation is precisely similar to that which takes place in 
head presentations, and, like it, depends on the movements imparted to 
the shoulders. 

M ado-posterior Positions in which Rotation does Not take Place. — Such 
is the natural course of delivery in the vast majority of cases ; but in 
order fully to understand the subject it is necessary to study those rare 
cases in which the chin points backward and forward rotation does not 



PRESEXTATIOyS OF THE FACE. 



315 



occur. These may be taken to correspond to the occipito-posterior 
positions, in which the face is born looking to the pubes ; but, unlike 



Fig. 114. 




Passage of the Head through the External Parts in Face Presentation. 

them, it is only very exceptionally that delivery can be naturally com- 
pleted. The reason of this is obvious, for the occiput gets jammed 
behind the pubes, and there is no space for the fronto-mental diameter 



Fig. 115. 




Illustrating the Position of the Head when Forward Rotation of the Chill (loea Nol take Place. 

to pass the antero-posterior diameter of the nutlet (Fig. 1 15). Cases are 

indeed recorded in which delivery has been effected with the chin looking 



316 LABOR. 

posteriorly, but there is every reason to believe that this can only happen 
when the head is either unusually small or the pelvis unusually large. 
In such cases the forehead is pressed down until a portion appears at 
the ostium vaginae, when it becomes firmly fixed behind the pubes, and 
the chin, after many efforts, slips over the perineum. When this is 
effected flexion occurs, and the occiput is expelled without difficulty. 
The forehead is probably always on a lower level than the chin. 

Dr. Hicks 1 has published a paper in which he attempts to show that 
this termination of face presentations is not so rare as is generally sup- 
posed, and he gives a single instance in which he effected delivery with 
the forceps ; but he practically admits that special conditions are neces- 
sary, such as the "anteroposterior diameter of the outlet particularly 
ample" and a diminished size of the head. When delivery is effected 
it is probable, as Cazeaux has pointed out, that the face lies in the oblique 
diameter of the outlet, and that the chin depresses the soft structures at 
the side of the sacro-ischiatic notch, which yield to the extent of a quar- 
ter of an inch or more, and thereby permit the passage of the occipito- 
mental diameter of the head. It must, however, be borne well in mind 
that spontaneous delivery in mento-posterior positions is the rare excep- 
tion, and that, supposing rotation does not occur — and it often does so at 
the last moment — artificial aid in one form or another will be almost 
certainly required. 

Prognosis of Face Presentations. — As regards the mother, in the great 
majority of cases the prognosis is favorable, but the labor is apt to be 
prolonged, and she is therefore more exposed to the risks attending tedi- 
ous delivery. As regards the child, the prognosis is much more unfav- 
orable than in vertex presentations. Even when the anterior rotation 
of the chin takes place in the natural way, it is estimated that 1 out of 
10 children is stillborn, while if not the death of the child is almost 
certain. This increased infantile mortality is evidently due to the serious 
amount of pressure to which the child is subjected, and probably depends 
in many cases on cerebral congestion, produced by pressure on the jugu- 
lar veins as the neck lies in the pelvic cavity. Even when the child is 
born alive, the face is always greatly swollen and disfigured. In some 
cases the deformity produced in this way is excessive and the features 
are often scarcely recognizable. This disfiguration passes away in a few 
days, but the practitioner should be aware of the probability of its 
occurrence, and should warn the friends, or they might be unnecessarily 
alarmed, and possibly might lay the blame on him. 

Treatment. — After what has been said as to the mechanism of delivery 
in face presentation, it is obvious that the proper course is to leave the 
case alone, in the expectation of the natural efforts being sufficient to 
complete delivery. Fortunately, in the large majority of cases this 
course is attended by a successful result. 

The older accoucheurs, as has been stated, thought active interference 
absolutely essential, and recommended either podalic version or the 
attempt to convert the case into a vertex presentation by inserting the 
hand and bringing down the occiput. The latter plan was recommended 
by Baudelocque, and is even yet followed by some accoucheurs. Thus, Dr. 

1 06s/. Trans., vol. vii. 



PBESEXTATIOXS OF THE FACE. 317 

Hoclge 1 advises it in all cases in which face presentation is detected at 
the brim ; but, although it might not have been attended with evil con- 
sequences in his experienced hands, it is certainly altogether unnecessary, 
and would infallibly lead to most serious results if generally adopted. 
It may, however, be allowable in certain cases in which the face remains 
above the brim and refuses to descend into the pelvic cavity. Even 
then it is questionable whether podalic version should not be pre- 
ferred, as being easier of performance, giving, when once effected, a 
much more complete control over delivery, and being less painful to 
the mother. Version is certainly preferable to the application of the 
forceps, which are introduced with difficulty in so high a position of 
the face, and do not take a secure hold. 

Rectification by Abdominal Palpation. — Schatz 2 has more recently 
suggested the rectification of face presentations at an early stage, before 
the rupture of the membranes, by manipulation through the abdomen. 
He raises the foetal body by pressure on the shoulder and breast through 
the abdominal wall by one hand, while the breech is raised and steadied 
by the other. By this means the occiput is elevated, and then the 
breech is pressed downward, when head flexion is produced by the 
resistance of the pelvic walls. Of this method I have had no practical 
experience, but it obviously requires an unusual amount of skill and 
practice in abdominal palpation. 

Difficulties from Arrest in the Pelvic Cavity. — When once the face has 
descended into the pelvis, difficulties may arise from two chief causes — 
uterine inertia and non-rotation forward of the chin. 

The treatment of the former class must be based on precisely the same 
general principles as in dealing with protracted labor in vertex presenta- 
tions. The forceps may be applied with advantage, bearing in mind 
the necessity of getting the chin under the pubes, and, when this has 
been effected, of directing the traction forward, so as to make the occiput 
slowly and gradually distend and sweep over the perineum. 

Difficulties arising from Non-rotation of Chin Fonvard. — The second 
class of difficult face cases are much more important, and may try the 
resources of the accoucheur to the utmost. Our first endeavor must be, 
if possible, to secure the anterior rotation of the chin. For this purpose 
various manoeuvres are recommended. By some we are advised to 
introduce the finger cautiously into the mouth of the child and draw 
the chin forward during a pain ; by others, to pass the finger up behind 
the occiput and press it backward during the pain. Schroeder points 
out that the difficulty often depends on the fact of the head not being 
sufficiently extended, so that the chin is not on a lower level than the 
forehead, and that rotation is best promoted by pressing the forehead 
upward with the finger during a pain, so as t<> cause the chin to descend. 
Penrose 3 believes that non-rotation i> generally caused by the want 
of a point d\ijjjjni below, on account of the face being unable to de- 
scend to the floor of the pelvis, and that if this is supplied rotation will 
take place. In such cases he applies the hand or the blade of the for- 
ceps, so as to press on the posterior cheek. By this means the neces- 

1 System of Obstetrics, [>. 335. 1./ Oyn. } B. v. 313. 

3 Amer. Supplement to Obst. Journ., April, l s 7''>. 



318 LABOR. 

sary point d'appui is given ; and he relates several interesting cases in 
which this simple manoeuvre was effectual in rapidly terminating a pre- 
viously lengthy labor. Any or all of these plans may be tried. We 
must bear in mind, in using them, that rotation is often delayed until 
the face is quite at the lower pelvic strait, so that we need not too soon 
despair of its occurring. If, however, in spite of these manoeuvres, it 
do not take place, what is to be done ? If the head be not too low down 
in the pelvis to admit of version, that would be the simplest and most 
effectual plan. I have succeeded in delivering in this way when all 
attempts at producing rotation had failed ; but generally the face will be 
too decidedly engaged to render it possible. An attempt might be made 
to bring down the occiput by the vectis or by a fillet, but if the face be 
in the pelvic cavity it is hardly possible for this plan to succeed. An 
endeavor may be made to produce rotation by the forceps ; but it should 
be remembered that rotation of the face mechanically in this Avay is very 
difficult, and much more likely to be attended with fatal consequences 
to the child than when it is effected by the natural efforts. In using 
forceps for this purpose, the second or pelvic curve is likely to prove 
injurious, and a short straight instrument is to be preferred. If rotation 
be found to be impossible, an endeavor may be made to draw the face 
downward, so as to get the chin over the perineum and deliver in the 
mento-posterior position ; but, unless the child be small or the pelvis 
very capacious, the attempt is unlikely to succeed. Finally, if all these 
means fail there is no resource left but lessening the size of the head by 
craniotomy — a dernier ressort which, fortunately, is very rarely required. 

Broio Presentations. — It sometimes happens that the head is partially 
extended, so as to bring the os frontis into the brim of the pelvis and 
form what is described as a "brow presentation" Should the head 
descend in this manner, the difficulties, although not insuperable, are 
apt to be very great, from the fact that the long cervico-frontal diameter 
of the head is engaged in the pelvic cavity. The diagnosis is not diffi- 
cult, for the os frontis w r ill be detected by its rounded surface, while the 
anterior fontanelle is within reach in one direction, the orbit and root 
of the nose in another. 

Spontaneously Converted into Face or Vertex Presentations. — Fortu- 
nately, in the large majority of cases brow presentations are spontane- 
ously converted into either vertex or face presentations, according as 
flexion or extension of the head occurs ; and these must be regarded 
as the desirable terminations and the ones to be favored. For this pur- 
pose upward pressure must be made on one or other extremity of the 
presenting part during a pain, so as to favor flexion or extension • or, 
if the parts be sufficiently dilated, an attempt may be made to pass the 
hand over the occiput and draw it down, thus performing cephalic ver- 
sion. The latter is the plan recommended by Hodge, who describes the 
operation as easy. It is questionable, however, if a well-marked brow 
presentation be distinctly made out while the head is still at the brim, 
whether podalic version would not be the easiest and best operation. If 
the forehead have descended too low for this, and if the endeavor to 
convert it into either a face or vertex presentation fail, the forceps will 
probably be required. In such cases the face generally turns toward 



DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 319 

the pubes, the superior maxilla becomes fixed behind the pubic arch, 
and the occiput sweeps over the perineum. Very great difficulty is 
likely to be experienced, and, if conversion into either a vertex or face 
presentation cannot be effected, craniotomy is not unlikely to be required. 



CHAPTER VII. 

DIFFICULT OCCIPITO-POSTFEIOK POSITIONS. 

A few words may be said in this place as to the management of 
occipito-posterior positions of the head, especially of those in which 
forward rotation of the occiput does not take place. It has already been 
pointed out that in the large majority of these cases the occiput rotates 
forward without any particular difficulty, and the labor terminates in 
the usual way, with the occiput emerging under the arch of the pubes. 

Rotation Forward of the Occiput. — In a certain number of cases such 
rotation does not occur, and difficulty and delay are apt to follow. The 
proportion of cases in which face-to-pubes terminations of occipito-pos- 
terior positions occur has been variously estimated, and they are certainly 
more common than most of our text-books lead us to expect. Dr. 
Uvedale West, 1 who studied the subject with great care, found that labor 
ended in this way in 79 out of 2585 births, all these deliveries being 
exceptionally difficult. 

Causes of Face-to-Pubes Delivery. — He believed that forward rotation 
of the head is prevented by the absence of flexion of the chin on the 
sternum, so that the long occipito-frontal, instead of the short sub- 
occipito-bregmatie, diameter of the head is brought into contact with the 
pelvic diameter; hence the occiput is no longer the lowest point, and is 
not subjected to the action of those causes which produce forward rota- 
tion. Dr. Macdonald, who has written a thoughtful paper on the sub- 
ject, 2 believe- that the non-rotation forward of the occiput is chiefly due 
to the large size of the head, in consequence of which "the forehead gets 
SO wedged into the pelvis anteriorly that its tendency to slacken and 
rotate forward doe- not come into play." Dr. West's interpretation, which 
has an important bearing on the management of these cases, seem- t<> 
explain mo3t correctly the non-occurrence of the natural rotation. 

The important question for us to decide is, How can we best assist in 
the management of cases of this kind when difficulties arise and labor is 
seriously retarded ? 

Mode of Treatment. — Dr. West, insisting strongly on the necessity of 
complete flexion of the chin on the sternum, advises that this should be 
favored by upward pressure on the frontal bone, with the view of causing 
the chin to approach the sternum and the occiput to descend, and thus to 
come within the action of the agencies which favor rotation. Supposing 

1 Cranial Presentations, p. 33. z Fdin. Mai. Journ., Oct.. 187 1. 



320 LABOR. 

the pains to be strong and the fontanelle to be readily within reach, we 
may in this way very possibly favor the descent of the occiput, and 
without injuring the mother or increasing the difficulties of the case in 
the event of the manoeuvre failing. The beneficial effects of this simple 
expedient are sometimes very remarkable. In two cases in which I 
recently adopted it labor, previously delayed for a length of time without 
any apparent progress, although the pains were strong and effective, was 
in each instance rapidly finished almost immediately after the upward 
pressure was applied. The rotation of the face backward may at the 
same time be favored by pressure on the pubic side of the forehead 
during the pains. 

Traction on the Occiput. — Others have advised that the descent of the 
occiput should be promoted by downward traction, applied by the vectis 
or fillet. The latter is the plan specially advocated by Hodge ; l and the 
fillet certainly finds one of its most useful applications in cases of this 
kind, as being simpler of application and probably more effective than 
the vectis. 

Over-active Endeavors at Assistance should be Avoided. — Although 
any of these methods may be adopted, a word of caution is necessary 
against prolonged and over-active endeavors at producing flexion, and 
rotation when that seems delayed. All who have watched such cases 
must have observed that rotation often occurs spontaneously at a very 
advanced period of labor, long after the head has been pressed down for 
a considerable time to the very outlet of the pelvis, and when it seems to 
have been making fruitless endeavors to emerge ; so that a little patience 
will often be sufficient to overcome the difficulty. 

When Necessary, the Forceps may be Used. — In the event of assistance 
being absolutely required there is no reason why the forceps should not 
be used. The instrument is not more difficult to apply than under 
ordinary circumstances, nor, as a rule, is much more traction necessary. 
Dr. Macdonald, indeed, in the paper already alluded to, maintains that 
in persistent occipito-posterior positions there is almost always a want of 
proportion between the head and the pelvis, and that, therefore, the 
forceps will be generally required ; and he prefers them to any artificial 
attempts at rectification. Some peculiarities in the mode of delivery are 
necessary to bear in mind. In most works it is taught that the operator 
should pay special attention to the rotation of the head, and should 
endeavor to impart this movement by turning the occiput forward during 
extraction. Thus, Tyler Smith says : " In delivery with the forceps in 
occipito-posterior presentations the head should be slowly rotated during 
the process of extraction, so as to bring the vertex toward the pubic 
arch, and thus convert them into occipito-anterior presentations." The 
danger accompanying any forcible attempt at artificial rotation will, 
however, be evident on slight consideration. It is true that in many 
cases, when simple traction is applied, the occiput will of itself rotate 
forward, carrying the instrument with it. But that is a very different 
thing from forcibly twisting round the head with the blades of the 
forceps, without any assurance that the body of the child will follow the 
movement. It is impossible to conceive that such violent interference 

1 System of Obstetrics, p. 308. 



DIFFICULT OCCIPITO-POSTERIOR POSITIONS. 321 

should not be attended with serious risk of injury to the neck of the 
child. If rotation do not occur, the fair inference is that the head is so 
placed as to render delivery with the face to the pubes the best termina- 
tion, and no endeavor should be made to prevent it. This rule of 
leaving the rotation entirely to nature, and using traction only, has 
received the approval of Barnes and most modern authorities, and is 
the one which recommends itself as the most scientific and reasonable. 

Objection to Curved Instruments in such Cases. — There are cases in 
which the pelvic curve of the forceps is of doubtful utility. "When 
applied in the usual way the convexity of the blades points backward. 
If rotation accompany extraction, the blades necessarily follow the 
movement of the head, and their convex edges will turn forward. It 
certainly seems probable that such a movement would subject the 
maternal soft parts to considerable risk. I have, however, more than 
once seen such rotation of the instrument happen without any apparent 
bad result ; but the dangers are obvious. Hence it would be a wise pre- 
caution either to use a pair of straight forceps for this particular opera- 
tion, or to remove the blades and leave the case to be terminated by the 
natural powers when the head is at the lower strait and rotation seems 
about to occur. "When there is no rotation, more than usual care should 
be taken with the perineum, which is necessarily much stretched by the 
rounded occiput. Indeed, the risk to the perineum is very considerable, 
and even with the greatest care it may be impossible to avoid laceration. 

Bearing these precautions in mind, delivery with the forceps in occipito- 
posterior positions offers no special difficulties or dangers. 

[ Version by the Vertex. — In order to adapt this section to American 
practice, I addressed letters of inquiry upon the management of oecipito- 
posterior positions to several obstetrical professors and teachers, and have 
prepared these instructions in accordance with their views. 

1. "In primitive oblique occipito-posterior positions of the head 
nature ^vill almost, without exception, cause spontaneous rotation of the 
occiput to the symphysis pubis ; but to favor this movement the bag of 
waters should be preserved." 

2. "Spontaneous rotation, as a rule, does not begin until the head 
meets with resistance from the floor of the pelvis ; hence no effort to 
fore*- potation should be made until Nature has proved herself inadequate." 

3. Where rotation forward is prevented, it is probably due to the 
position of the occiput having been originally directly backward, and 
only becoming oblique after the descenl of the head into the pelvis, the 
position of the child's body preventing the anterior movement of its 
occiput. That is, the sixth position of Hodge has changed into a fourth 
or fifth, but will not without assistance become a fifsl or second. 

4. If, then, rotation is not spontaneous after the head reaches the 
floor of the pelvis, version by the vertex will not take place except it he 
forced by- the vectis or forceps. 

One professor writes: "] have thus far succeeded so well" (i. <■ by 
the vectis and forceps) "that I recall but one instance in which the head 
was born with the occiput looking to the sacrum." Another says he 
applies the forceps and lets "the progress of the head determine the 
mode bv which it shall make its exit, not trying to turn by the forceps." 
21 



322 LABOR. 

In the primitive occipito-sacral position changed to oblique, or in the 
more rare unchanged sixth position of Hodge, if the head is large or the 
pelvis in any way obstructed, the case may require to be terminated by 
craniotomy. It is even possible to rotate the occiput from the sacrum 
to the pubes and save the child, as this was once done by the late Dr. 
William Harris of Philadelphia. Of course the body must have partly 
rotated. 

Use of the Hand in Oeeipito-posterior Positions. — The introduction 
of the hand for the purpose of effecting version by the vertex, under an 
anaesthetic, was strongly advocated by the late Dr. John S. Parry 1 of 
Philadelphia, who certainly used his own, which was small and thin, to 
very great advantage. Several very small-handed accoucheurs in this 
city have found their hands of very great value in some cases of 
obstetrics ; and it is said that a celebrated Neapolitan obstetrician owes 
his great popularity to the advantage thus derived. It will not do to 
advocate a general use of the hand in obstetric practice, as few have such 
as it would be safe to use, especially in primiparae. I have known a 
primipara labor for hours to deliver herself of a foetus in an oeeipito- 
posterior position, when' all that was needed was the assistance of a 
suitable hand during three labor-pains to bring the occiput fairly under 
the arch of the pubis.— Ed.] 



CHAPTER VIII. 



PKESENTATIONS OF THE SHOULDER, AEM, OR TRUNK— COMPLEX 
PRESENTATIONS— PROLAPSE OF THE FUNIS. 

In the presentations already considered the long diameter of the foetus 
corresponded with that of the uterine cavity, and in all of them the birth 
of the child by the maternal efforts was the general and normal termina- 
tion of labor. We have now to discuss those important cases in which 
the long diameter of the foetus and uterus do not correspond, but in 
which the long foetal diameter lies obliquely across the uterine cavity. 
In the large majority of these it is either the shoulder or some part of 
the upper extremity that presents; for it is an admitted fact that, 
although other parts of the body, such as the back or abdomen, may, in 
exceptional cases, lie over the os at an early period of labor, yet as labor 
progresses such presentations are almost always converted into those of 
the upper extremity. 

For all practical purposes, we may confine ourselves to a considera- 
tion of shoulder presentations, the further subdivision of these into elbow 
or hand presentations being no more necessary than the division of pel- 
vis presentations into breech, knee, and footling eases, since the mechan- 
ism and management are identical whatever part of the upper extremity 
presents. 

\} Am. Joiini. Obstetrics, May, 1875.] 



PRESENTATIONS OF SHOULDER, ETC. 323 

Delivery by the Natural Powers is Quite Exceptional. — There is this 
great distinction between the presentations we are now considering and 
those already treated of: that, on account of the relations of the foetus 
to the pelvis, delivery by the natural powers is impossible, except under 
special and very unusual circumstances that can never be relied upon. 
Intervention on the part of the accoucheur is therefore absolutely essen- 
tial, and the safety of both the mother and child depends upon the early 
detection of the abnormal position of the foetus ; for the necessary treat- 
ment, which is comparatively easy and safe before labor has been long 
in progress, becomes most difficult and hazardous if there have been 
much delay. 

Position of the Foetus. — Presentations of the upper extremity or trunk 
are often spoken of as " transverse presentations " or " cross-births ; " 
but both of these terms are misleading, as they imply that the foetus is 
placed transversely in the uterine cavity or that it lies directly across the 
pelvic brim. As a matter of fact, this is never the case, for the child 
lies obliquely in the uterus — not indeed in its long axis, but in one inter- 
mediate between its long and transverse diameters. 

Divided into Dorso-anterior and Dor so-posterior Positions. — Two 
great divisions of shoulder presentations are recognized : the one in 

Fig. 116. 




Dorso-anterior Presentation of the Arm. 

which the back of the child looks to the abdomen of the mot her ( Fig. 
116), and the other in which the back of the child is turned toward the 
spine of the mother (Fig. 1 17). Kadi of these is subdivided into two 
subsidiary classes, according as the head of the child is placed in the 
righl or left iliac fossa. Thus, in dorso-anterior positions, if the head 
lie in the left iliac fossa, the right shoulder of the child presents; if in 
the right iliac fossa, the left. So in dorso-posterior positions, if the head 
lie in the left iliac fossa, the left shoulder presents ; if in the right, the 
right. Of the two classes, the dorso-anterior position- are more com- 
mon, in the proportion, it is said, of two to one. 



324 LABOR. 

Causes. — The causes of shoulder presentation are not well known. 
Amongst those most commonly mentioned are prematurity of the foetus 
and excess of liquor amnii ; either of these, by increasing the mobility 
of the foetus in utero, would probably have considerable influence. The 
fact that it occurs much more frequently amongst premature births has 

Fig. 117. 




Dorso-posterior Presentation of the Arm. 

long been recognized. Undue obliquity of the uterus has probably some 
influence, since the early pains might cause the presenting part to hitch 
against the pelvic brim and the shoulder to descend. An unusually low 
attachment of the placenta to the inferior segment of the uterine cavity 
has been mentioned as a predisposing cause. In consequence of this the 
head does not lie so readily in the lower uterine segment, and is apt to 
slip up into one of the iliac fossse. This is supposed to explain the fre- 
quency of arm presentation in cases of partial or complete placenta 
prsevia. Danyau and Wigand believe that shoulder presentations are 
favored by irregularity in the shape of the uterine cavity, especially a 
relative increase in its transverse diameter. This theory has been gen- 
erally discredited by writers, and it is certainly not susceptible of proof ; 
but it seems far from unlikely that some peculiarity of shape may exist, 
not capable of recognition, but sufficient to influence the position of the 
foetus. How otherwise are we to explain those remarkable cases, many 
of which are recorded, in which similar malpositions occurred in many 
successive labors ? Thus, Joulin refers to a patient who had an arm 
presentation in three successive pregnancies, and to another who had 
shoulder presentation in three out of four labors. Certainly, such con- 
stant recurrences of the same abnormality could only bo explained on 
the hypothesis of some very persistent cause, such as that referred to. 
Pinard 1 states that shoulder presentations are seven times more common 

1 Amud. d'Hyg. Pub. et de Med., Jan., 1879. 



PRESENTATIONS OF SHOULDER, ETC. 325 

in multipara than in primiparse, in consequence, as he believes, of the 
laxity of the abdominal walls in the former, which allows the uterus to 
fall forward, and thus prevents the head entering the pelvic brim in the 
latter weeks of pregnancy. It is probable that merely accidental causes 
have most influence in the production of shoulder presentation, such as 
falls or undue pressure exerted on the abdomen by badly-fitting or tight 
stays. Partially transverse positions during pregnancy are certainly 
much more common than is generally believed, and may often be 
detected by abdominal palpation. The tendency is for such malposi- 
tions to be righted either before labor sets in or in the early period of 
labor ; but it is quite easy to understand how any persistent pressure, 
applied in the manner indicated, may perpetuate a position which other- 
wise would have been only temporary. 

Prognosis and Frequency. — According to Churchill's statistics, 
shoulder presentations occur about once in 260 cases ; that is, only 
slightly less frequently than those of the face. The prognosis to both 
the mother and child is much more unfavorable ; for he estimates that, 
out of 235 cases, 1 in 9 of the mothers and half the children were lost. 
The prognosis in each individual case will, of course, vary much with 
the period of delivery at which the malposition is recognized. If 
detected early, interference is easy and the prognosis ought to be good ; 
whereas there are few obstetric difficulties more trying than a case of 
shoulder presentation in which the necessary treatment has been delayed 
until the presenting part has been tightly jammed into the cavity of the 
pelvis. 

Diagnosis. — Bearing this fact in mind, the paramount necessity of an 
accurate diagnosis will be apparent ; and it is specially important that 
we should be able not only to detect that a shoulder or arm is present- 
ing, but that we should, if possible, determine which it is, and how the 
body and head of the child are placed. The existence of a shoulder 
presentation is not generally suspected until the first vaginal examination 
is made during labor. The practitioner will then be struck with the 
absence of the rounded mass of the foetal head, and, if the os be open 
and the membranes protruding, by their elongated form, which is com- 
mon to this and to other malpresentations. If the presenting part be 
too high to reach, as is often the case at an early period of labor, an 
endeavor should at once be made to ascertain the foetal position by 
abdominal examination. This is the more important ;is it is much more 
easy to recognize presentations of the shoulder in this way than those 
of the breech or foot; and at so early a period it is often not only possi- 
ble, but comparatively easy, to alter the position of the foetus by abdom- 
inal manipulation alone, and thus avoid the necessity of the more serious 
form of version. The method of detecting a shoulder presentation by 
examination of the abdomen has already been described (p. L 24), and 
need not be repeated. The chief point- to look for are the altered shape 
of the uterus and two Solid masses, the head and the breech, one in either 
iliac fossa. The facility with which these part- may be recognized varies 
much in different patients. In thin women with lax abdominal parietes 
they can be easily felt, while in very -tout women it may be impossible. 
Failing this method, we must rely on vaginal examinations, although 



326 LABOR. 

before the membranes are ruptured, and when the presenting part is high 
in the pelvis, it is not always easy to gain accurate information in this 
way. The difficulty is increased by the paramount importance of retain- 
ing the membranes intact as long as possible. It should be remembered, 
therefore, that when a presentation of the superior extremity is suspected, 
the necessary examinations should only be made in the intervals between 
the pains, when the membranes are lax, and never when they are ren- 
dered tense by the uterine contractions. 

As either the shoulder, the elbow, or the hand may present, it will be 
best to describe the peculiarities of each separately, and the means of 
distinguishing to which side of the body the presenting part belongs. 

1. Peculiarities of the Shoulder. — The shoulder is recognized as a 
round, smooth prominence, at one point of which may often be felt the 
sharp edge of the acromion. If the finger can be passed sufficiently 
high, it may be possible to feel the clavicle and the spine of the scapula. 
A still more complete examination may enable us to detect the ribs and 
the intercostal spaces, which would be quite conclusive as to the nature 
of the presentation, since there is nothing resembling them in any other 
part of the body. At the side of the shoulder the hollow of the axilla 
may generally be made out. 

Mode of Diagnosing the Position of the Child. — In order to ascertain 
the position of the child we have to find out in which iliac fossa the head 
lies. This may be done in two ways : 1st, the head may be felt through 
the abdominal parietes by palpation; and 2d, since the axilla always 
points toward the feet, if it point to the left side the head must lie in the 
right iliac fossa ; if to the right, the head must be placed in the left iliac 
fossa. Again, the spine of the scapula must correspond to the back of 
the child, the clavicle to its abdomen ; and by feeling one or other we 
know whether we have to do with a dorso-anterior or dorso-posterior 
position. If we cannot satisfactorily determine the position by these 
means, it is quite legitimate practice to bring down the arm carefully, 
provided the membranes are ruptured, so as to examine the hand, which 
will be easily recognized as right or left. This expedient will decide 
the point, but it is one which it is better to avoid if possible, for it not 
only slightly increases the difficulty of turning, although perhaps not 
very materially, but the arm might possibly be injured in the endeavor 
to bring it down. 

Differential Diagnosis of the Shoulder. — The only part of the body 
likely to be taken for the shoulder is the breech ; but in that its larger 
size, the groove in which the genital organs lie, the second prominence 
formed by the other buttock, and the sacral spinous processes are suffi- 
cient to prevent a mistake. 

2. The Elbow. — The elbow is rarely felt at the os, and may be readily 
recognized by the sharp prominence of the olecranon, situated between 
two lesser prominences, the condyles. As the elbow always points 
toward the feet, the position of the foetus can be easily ascertained. 

3. The Hand. — The hand is easy to recognize, and can only be con- 
founded with the foot. It can be distinguished by its borders being of 
the same thickness, by the fingers being wider apart and more readily 
separated from each other than the toes, and above all by the mobility 



PRESENTATIONS OF SHOULDER, ETC. 327 

of the thumb, which can be carried across the palm and placed in appo- 
sition with each of the fingers. 

Mode of Detecting which Hand is Presenting. — It is not difficult to 
tell which hand is presenting. If the hand be in the vagina or beyond 
the vulva, and within easy reach, we recognize which it is by laying hold 
of it as if we were about to shake hands. If the palm lie in the palm 
of the practitioner's hand with the two thumbs in apposition, it is the 
right hand ; if the back of the hand, it is the left. Another simple way 
is for the practitioner to imagine his own hand placed in precisely the 
same position as that of the foetus, and this will readily enable him to 
verify the previous diagnosis. A simple rule tells us how the body of 
the child is placed, for, provided we are sure the hand is in a state of 
supination, the back of the hand points to the back of the child, the 
palm to its abdomen, the thumb to the head, and the little finger to 
the feet. 

Mechanism. — It is perhaps hardly proper to talk of a mechanism of 
shoulder presentations, since if left unassisted they almost invariably 
lead to the gravest consequences. Still, Nature is not entirely at fault 
even here, and it is well to study the means she adopts to terminate 
these malpositions. 

Terminations. — There are two possible terminations of shoulder pres- 
entation. In one, known as "spontaneous version" some other part of 
the foetus is substituted for that originally presenting ; in the other, 
" spontaneous evolution" the foetus is expelled by being squeezed through 
the pelvis, without the originally presenting part being withdrawn. It 
cannot be too strongly impressed on the mind that neither of these can 
be relied on in practice. 

Sjjoiitri neous version may occasionally occur before or immediately 
after the rupture of the membranes, when the foetus is still readily 
movable within the cavity of the uterus. A few authenticated cases are 
recorded in which the same fortunate issue took place after the shoulder 
had been engaged in the pelvic brim for a considerable time, or even 
after prolapse of the arm ; but its probability is necessarily much less- 
ened under such circumstances. Either the head or the breech may be 
brought down to the os in place of the original presentation. 

The precise mechanism of spontaneous version, or the favoring cir- 
cumstances, are not sufficiently understood to justify any positive state- 
ment with regard to it. 

Cazeaux believed that it is produced by partial or irregular contrac- 
tion of the uterus, one side contracting energetically, while the other 
remains inert or only contracts to a slight degree. To illustrate how 
this may effect spontaneous version, let us suppose that the child is lying 
with the head in the left iliac fossa. Then, if I lie left side of the uterus 
should contract more forcibly than the right, it would clearly tend to 
push the head and shoulder to the right side until the head came to pre- 
sent instead of the shoulder. A very interesting ease is related by 
Geneuil 1 in which he was present during spontaneous version, in the 
course of which the breech was substituted \'"V the left shoulder more 
than four hours after the rupture of the membranes. In tin- case the 

1 Ann. de Qyn&cologie, vol. v., 1876. 



328 LABOR. 

uterus was so tightly contracted that version was impossible. He ob- 
served the side of the uterus opposite the head contracting energetically, 
the other remaining flaccid, and eventually the case ended without assist- 
ance, the breech presenting. The natural moulding action of the uterus, 
and the greater tendency of the long axis of the child to lie in that of 
the uterus, no doubt assist the transformation • and much must depend 
on the mobility of the fetus in any individual case. 

That such changes often take place in the latter weeks of pregnancy, 
and before labor has actually commenced, is quite certain, and they are 
probably much more frequent than is generally supposed. When spon- 
taneous version does occur, it is of course a more favorable event ; and 
the termination and prognosis of the labor are then the same as if the 
head or breech had originally presented. 

Spontaneous Evolution. — The mechanism of spontaneous evolution, 
since it was first clearly worked out by Douglas, has been so often and 
carefully described that we know precisely how it occurs. Although 
every now and then a case is recorded in w T hich a living child has been 
born by this means, such an event is of extreme rarity ; and there is no 
doubt of the accuracy of the general opinion, that spontaneous evolution 
can only happen when the pelvis is unusually roomy and the child 
small, and that it almost necessarily involves the death of the foetus, 
on account of the immense pressure to which it is subjected. 

Two varieties are described, in one of which the head is first born, in 
the other the breech ; in both the originally presenting arm remained 
prolapsed. The former is of extreme rarity, and is believed only to 
have happened with very premature children, whose bodies were small 
and flexible, and w r hen traction had been made on the presenting arm. 
Under such circumstances it can hardly be called a natural process, and 
we may confine our attention to the latter and more common variety. 

What takes place is as follows : The presenting arm and shoulder are 
tightly jammed down, as far as is possible, by the uterine contractions, 
and the head becomes strongly flexed on the shoulder. As much of the 
body of the foetus as the pelvis will contain becomes engaged, and then 
a movement of rotation occurs which brings the body of the child nearly 
into the antero-posterior diameter of the pelvis (Fig. 118). The shoul- 
der projects under the arch of the pubes, the head lying above the sym- 
physis and the breech near the sacro-iliac synchondrosis. It is essential 
that the head should lie forward above the pubes, so that the length of 
the neck may permit the shoulder to project under the pubic arch, with- 
out any part of the head entering the pelvic cavity. The shoulder and 
neck of the child now become fixed points round which the body of the 
child rotates, and the whole force of the uterine contractions is expended 
on the breech. The latter, with the body, therefore becomes more and 
more depressed, until at last the side of the thorax reaches the vulva, 
and, followed by the breech and inferior extremities, is slowly pushed 
out. As soon as the limbs are born the head is easily expelled. 

The enormous pressure to which the body is subjected in this process 
can readily be understood. As regards the practical bearings of this 
termination of shoulder presentations, all that need be said is, that if 
we should happen to meet with a case in which the shoulder and thorax 



PRESENTATIONS OF SHOULDER, ETC. 



329 



were so strongly depressed that turning was impossible, and in which it 
seemed that nature was endeavoring to effect evolution, we should be 
justified in aiding the descent of the breech by traction on the groin 
before resorting to the difficult and hazardous operation of embryotomy 
or decapitation. 

Treatment. — It is unnecessary to describe specially the treatment of 
shoulder presentation, since it consists essentially in performing the 
operation of turning, which is fully described elsewhere. It is only 

Fig. 118. 




Spontaneous Evolution. (After Chiara of Milan.) 
This drawing was made from a patient who died undelivered, the bodj being frozen and bisected. 

needful here to insist on the advisability of performing the operation 
in the way which involves the leasl interference with the uterus. Hence 
if the nature of the case be detected before the membranes are ruptured, 
an endeavor should he made — and OUghl generally to succeed — to turn 
by external manipulation only. If we can succeed in bringing the 
breech or head over the os in this way, the case will be little more 
troublesome than an ordinary presentation <>f these parts. Failing in 
this, turning by combined external and internal manipulation should be 
attempted, and the introduction of the entire hand should be reserved 
for those more troublesome cases in which the water- have long drained 
away and in which both these methods are inapplicable. 



330 LABOR. 

Should all these means fail, we must resort to the mutilation of the 
child by embryulcia or decapitation, probably the most difficult and 
dangerous of all obstetric operations. [*] 

Complex Presentations. — There are various so-called complex presenta- 
tions in which more than one part of the foetal body presents. Thus we 
may have a hand or a foot presenting with the head, or a foot and hand 
presenting simultaneously. The former does not necessarily give rise to 
any serious difficulty, for there is generally sufficient room for the head 
to pass. Indeed, it is unlikely that either the hand or foot should enter 
the pelvic brim with the head unless the head was unusually small or 
the pelvis more than ordinarily capacious. As regards treatment, it is 
no cloubt advisable to make an attempt to replace the hand or foot by 
pushing it gently above the head in the intervals between the pains, 
and maintaining it there until the head be fully engaged in the pelvic 
cavity. The engagement of the head can be hastened by abdominal 
pressure, which will prove of great value. Failing this, all we can do 
is to place the presenting member at the part of the pelvis where it 
will least impede the labor and be the least subjected to pressure ; and 
that will generally be opposite the temple of the child. As it must 
obstruct the passage of the head to a certain extent, the application of 
the forceps may be necessary. When the feet and hands present at the 
same time, in addition to the confusing nature of the presentation from 
so many parts being felt together, there is the risk of the hands com- 
ing down and converting the case into one of arm presentation. It 
is the obvious duty of the accoucheur to prevent this by ensuring the 
descent of the feet, and traction should be made on them, either with 
the fingers or with a lac, until their descent and the ascent of the hands 
are assured. 

Dorsal Displacement of the Arm. — In connection with this subject 
may be mentioned the curious dorsal displacement of the arm, first 

\} Accoucheurs and surgeons have thought proper to perform the Cesarean opera- 
tion in the United States in 11 cases where the foetus was dead and impacted in the 
pelvis in a transverse position, and of these 8 were saved, or 72 T 8 T per cent. In 9 of 
the cases the arm protruded. In 3 the pelvis was small, but in two of these, small chil- 
dren have since been delivered alive naturally. In no case in the list was there any 
evidence of pelvic disease. In a twelfth case, where there had been rickets in child- 
hood, and in which the arm protruded, there was likewise a saving of the woman ; but 
this one is excluded from the record, on account of the true cause of dystocia not 
having been the position of the foetus. Case 3 was in labor 96 hours, 3 days of this 
time under a midwife, and died of exhaustion in 17 hours. Case 7 was also in the care 
of a midwife, and died of exhaustion in 12 hours, having been much prostrated at the 
time of the operation. Case 9 was in a fair way to recover when her husband came 
home intoxicated, and she arose from her bed to protect her mother from him. This 
fright, excitement, and exertion caused her death in a few hours three and a half days 
after the operation. 

The celebrated case of Le Bras of Mouilleron in 1769, in which the uterus was for 
the first time sutured, was one of arm protrusion, with impaction, after three days' 
labor under a midwife: this patient also recovered. Le Bras was much censured for 
bis operation, although Dr. Lyonnet had labored a long time to deliver per vias naiu- 
rales before he was called in, and particularly for the additional risk of inserting a 
movable suture in the uterus. Certainly the results of these American operations are 
encoura,nin<; in this class of cases. Case 11 was operated upon in June, 1880, and bad 
two silver-wire uterine sutures inserted : she was well in a month, pregnant in two and 
a half more, and bore a child naturally in twelve and a bait' months alter the opera- 
tion. Can craniotomy and evisceration show any more favorable results? — Ed.] 



PRESENTATIONS OF SHOULDER, ETC. 



described by Sir James Simpson/ in which the forearm of the child 
becomes thrown across and behind the neck. The result is the forma- 
tion of a ridge or bar, which prevents the descent of the head into the 
pelvis by hitching against the brim (Fig. 119). The difficulty of diag- 
nosis is very great, for the cause of obstruction is too high up to be felt. 
But if we meet with a case in which the pelvis is roomy and the pains 
strong, and yet the head does not descend after an adequate time, a full 
explanation of the cause is essential. For this purpose we would natu- 
rally put the patient under chloroform and pass the hand sufficiently high. 

Fig. 120. 



Fig. 119. 





Dorsal Displacement of the 

Ai\n. 



Dorsal Displacement of the Ann in Footling 
Presentations. (After Barnes.) 



AVe might then feel the arm in its abnormal position. That was what 
took place in a case under my own care, in which 1 failed to get the 
head through the brim with the forceps, and eventually delivered by 
turning. The same course was adopted by my friend Mr. Jardine 
Murray in a similar case. 2 Simpson advises that the arm should be 
brought down, so as to convert the ease into an ordinary hand-and-head 
presentation. This, if the arm be above the brim, must always be diffi- 
cult, and I believe the simpler and more effective plan is podalic version. 
A similar displacement may cause some difficulty in breech presenta- 
tions and after turning (Fig. 120). Delay here is easier of diagnosis, 
since the obstacle to the expulsion will at once lead to careful examina- 
tion. ]>v carrying the body of the child well backward, so as to enable 



Selected Obslet. Works, vol. 



a Med. IHmea and Om., 1861. 



332 



LABOR. 



the finger to pass behind the symphysis pubis and over the shoulder, it 
will generally be easy to liberate the arm. 

Prolapse of the Umbilical Cord* — It occasionally happens that the 
umbilical cord falls down past the presenting part (Fig. 121), and is apt 
to be pressed between it and the walls of the pelvis. The consequence 
is, that the foetal circulation is seriously interfered with, and the death 

Fig. 121. 




Prolapse of the Umbilical Cord. 



of the child from asphyxia is a common result. Hence prolapse of the 
funis is a very serious complication of labor in so far as the child is 
concerned. 

Frequency. — Fortunately, it is not a very frequent occurrence. 
Churchill calculates that out of over 105,000 deliveries it was met with 
once in 240 cases, and Scanzoni once in 254. Its frequency varies much 
under different circumstances and in different places. We find from 
Churchill's figures a remarkable difference in the proportional number 
of cases observed in France, England, and Germany — viz. 1 in 446^-, 
1 in 207-|-, and 1 in 156, respectively. Great as is the proportion 
referred to Germany in these figures, it has been found to be exceeded in 
special districts. Thus, Engelmann records 1 case out of 94 labors in 
the Lying-in Hospital at Berlin, and Michael is 1 in 90 in that of Kiel. 
These remarkable differences are at first sight not easy to account for. 
Dr. Simpson suggests, with considerable show of probability, that the 
difference in frequency in England, France, and Germany may depend 
on the varying positions in which lying-in women are placed during 
labor in each country. In France, where, although the patient is laid 
on her back, the pelvis is kept elevated, the complication occurs least fre- 
quently ; in England, where she lies on her side, more often ; and in 
Germany, where she is placed on her back with her shoulders n 



PRESENTATIONS OF SHOULDER, ETC. 333 

most often. The special frequency of prolapsed funis in certain districts, 
as in Kiel, is supposed by Engelmann l to depend on the prevalence of 
rickets, and consequently of deformed pelvis, which we shall presently 
see is probably one of the most frequent and important causes of the 
accident. 

Prognosis. — With regard to the danger attending prolapsed funis, as 
far as the mother is concerned it may be said to be altogether unimport- 
ant ; but the universal experience of obstetricians points to the great risk 
to which the child is subjected. Scanzoni calculates that 45 per cent, 
only of the children were saved ; Churchill estimated the number at 47 
per cent. ; thus, under the most favorable circumstances, this complica- 
tion leads to the death of more than half the children. Engelmann 
found that out of 202 vertex presentations only 36 per cent, of the chil- 
dren survived. The mortality was not nearly so great in other pres- 
entations; 68 per cent, of the cases in which the child presented with 
the feet were saved, and 50 per cent, in original shoulder presentations. 
The reason of this remarkable difference is, doubtless, that in vertex 
presentations the head fits the pelvis much more completely and subjects 
the chord to much greater pressure, while in other presentations the pel- 
vis is less completely filled and the interference with the circulation in 
the cord is not so great. Besides, in the latter case the complication is 
detected early and the necessary treatment sooner adopted. 

The foetal mortality is considerably greater in first labors — a result to 
be expected on account of the greater resistance of the soft parts and 
the consequent prolongation of the labor. 

Causes. — The causes of prolapse of the funis are any circumstances 
which prevent the presenting part accurately fitting the pelvic brim. 
Hence it is much more frequent in face, breech, or shoulder than in ver- 
tex presentations, and is relatively more common in footling and shoul- 
der presentations than in any other. Amongst occasional accidental 
predisposing causes may be mentioned early rupture of the membranes, 
especially if the amount of liquor amnii be excessive, as the sudden 
escape of the fluid washes down the cord; undue length of the cord 
itself; or an unusually low placental attachment. Engelmann attaches 
great importance to slight contraction of the pelvis, and states that in 
the Berlin Lying-in Hospital, where accurate measurements of the pel- 
vis were taken in all eases, it was almost invariably found to exist. The 
explanation is evident, since one of the first results of pelvic contraction 
is to prevent the ready engagement of the presenting pari in the pelvic 
brim. 

Diagnosis. — The diagnosis of cord presentation is generally devoid 
of difficulty, but if the membranes are still unruptured it may not always 
be quite easy to determine the precise nature of the soft structures fell 
through them, as they recede from the touch. If the pulsations of the 
cord can be felt through the membranes, all difficulty is removed. After 
the membranes are ruptured there i> nothing that it can well be mi- 
taken for. 

Importance of Detenu ini ng the Pulsations of the Cord. — The important 
point to determine in such a case is whether the cord be pulsating or 
1 Amer. Journ. of Obst.. vol. vi. 



334 



LAB OB. 



not ; for if pulsations have entirely ceased the inference is that the child 
is dead, and the case may then be left to nature without further interfe- 
rence. It is of importance, however, to be careful, for if the examina- 
tion be made during a pain the circulation might be only temporarily 
arrested. The examination, therefore, should be made during an inter- 
val, and a loop of the cord pulled down, if necessary, to make ourselves 
absolutely certain on this point. 

Amount of Cord Prolapsed. — The amount of the prolapse varies much. 
Sometimes only a knuckle of the cord, so small as to escape observation, 
is engaged between the pelvis and presenting part. Under such circum- 
stances the child may be sacrificed without any suspicion of danger having 
arisen. More often the amount prolapsed is considerable — sometimes so 
as to lie in the vagina in a long loop, or even to protrude altogether 
beyond the vulva. 

Treatment. — In the treatment the great indication is to prevent the 
cord from being unduly pressed on, and all our endeavors must have 
this object in view. If the presentation be detected before the full dila- 
tation of the cervix and when the membranes are unruptured, we must 
try to keep the cord out of the way ; to preserve the membranes intact 
as long as possible, since the cord is tolerably protected as long as it is 
surrounded by the liquor amnii ; and to secure the complete dilatation 
of the os, so that the presenting part may engage rapidly and completely. 

Postural Treatment. — Much may be done at this time by the postural 
treatment, which we chiefly owe to the ingenuity of Dr. T. Gaillard 
Thomas of New York, whose writings familiarized the profession with 
it, although it appears that a somewhat similar plan had been occasion- 
ally adopted previously. Dr. Thomas's method is based on the principle 
of causing the cord to slip back into the uterine cavity by its own weight. 

Fig. 122. 




Postural Treatment of Prolapse of the Cord. 



For this purpose the patient is placed on her hands and knees, with the 
hips elevated and the shoulders resting on a lower level (Fig. 122). The 
cervix is then no longer the most dependent portion of the uterus, and 
the anterior wall of the uterus forms an inclined plane down which the 



PRESENTATIONS OF SHOULDER, ETC. 335 

cord slips. The success of this manoeuvre is sometimes very great, but 
by no means always so. It is most likely to succeed when the mem- 
branes are unruptured. If, when adopted, the cord slip away and the 
os be sufficiently dilated, the membranes may be ruptured, and engage- 
ment of the head produced by properly-applied uterine pressure. Some- 
times the position is so irksome that it is impossible to resort to it. 
Postural treatment is not even then altogether impossible, for by placing 
the patient on the side opposite to that of the prolapse, so as to relieve 
the cord as much as possible from pressure, and at the same time elevat- 
ing the hips by a pillow, it may slip back. Even after the membranes 
are ruptured postural treatment in one form or another may succeed ; 
and, as it is simple and harmless, it should certainly be always tried. 
Attempts at reposition by one or other of the methods described below 
may also occasionally be facilitated by trying them when the patient is 
placed in the knee-shoulder position. 

Artificial Reposition. — Failing by postural treatment, or in combina- 
tion with it, it is quite legitimate to make an attempt to place the cord 
beyond the reach of dangerous pressure by other methods. Unfortu- 
nately, reposition is too often disappointing, difficult to effect, and very 
frequently, even when apparently successful, shortly followed by a fresh 
descent of the cord. Provided the os be fully dilated and the presenting 
head engaged in the pelvis (for reposition may be said to be hopeless 
when any other part presents), perhaps the best Avay is to attempt it by 
the hand alone. Probably the simplest and most effectual method is that 
recommended by McCIintock and Hardy, who advise that the patient 
3hould lie on the opposite side to the prolapsed cord, which should then 
be drawn toward the pubes as being the shallowest part of the pelvis. 
Two or three fingers may then be used to push the cord past the head 
and as high as they can reach. They must be kept in the pelvis until a 
pain comes on, and then very gently withdrawn, in the hope that the 
cord may not again prolapse. During the pain external pressure may 
very properly be applied to favor descent of the head. This manoeuvre 
may be repeated (luring several successive pains, and may eventually 
3ucceed. The attempt to hook the cord over the fetal limbs or to place 
it in the hollow of the neck, recommended in many works, involves so 
deep an introduction of the hand that it is obviously impracticable. 

Instruments Used for Reposition. — Various complex instruments have 
been invented to aid reposition (Fig. 123), but even if we possessed them 
they are not likely to be at hand when the emergency arises. A simple 
instrumenl may be improvised out of an ordinary male elastic catheter 
by passing (he two ends of a piece of string through il, so as to leave a 
loop emerging from the eve of the catheter. This is passed through the 
loop of prolapsed cord, and then fixed in the eve of the catheter by 
means of the stilette. The cord is then pushed up into the uterine cavity 
by the catheter, and liberated by withdrawing the stilette. Another 
simple instrument may be made by cutting a hole in a piece of whale- 
bone. A piece of tape is then passed through the loop of the cord and 
the ends threaded through the eye cut in the whalebone. By tightening 
the tape; the whalebone is held in close apposition to the cord, and the 

whole is passed as high as possible into i]^' uterine cavity. The tape can 



336 



LAB OB. 



Fig. 123. 



easily be liberated by pulling one end. If preferred, the cord can be tied 
to the whalebone, which is left in utero until the child is born. Noth- 
ing need be said as to the various other methods adopted for keeping up 
the cord, such as the insertion of pieces of sponge or 
tying the cord in a bag of soft leather, since they are 
generally admitted to be quite useless. 

Treatment when Reposition Fails. — It only too often 
happens that all endeavors at reposition fail. The 
subsequent treatment must then be guided by the cir- 
cumstances of the case. If the pelvis be roomy and 
the pains strong, especially in a multipara, we may 
often deem it advisable to leave the case to nature, in 
the hope that the head may be pushed through before 
pressure on the cord has had time to prove fatal to the 
child. Under such circumstances the patient should 
be urged to bear clown, and the descent of the head 
promoted by uterine pressure, so as to get the second 
stage completed as soon as possible. If the head be 
within easy reach, the application of the forceps is 
quite justifiable, since delay must necessarily involve 
the death of the child. During this time the cord 
should be placed, if possible, opposite one or other 
sacro-iliac synchondrosis, according to the position of 
the head, as the part of the pelvis where there is the 
most room, and where the pressure would consequently 
be least prejudicial. If we have to do with a case in 
which the head has not descended into the pelvis, and 
postural treatment and reposition have both failed, pro- 
vided the os be fully dilated and other circumstances 
be favorable, turning would undoubtedly offer the best 
chance to the child. This treatment is strongly advo- 
cated by Engelmann, who found that 70 per cent, of the children delivered 
in this way were saved. There can be no question that, so far as the 
interests of the child are concerned, it is, under the circumstances indi- 
cated, by far the best expedient. Turning, however, is by no means 
always devoid of a certain risk to the mother, and the performance of 
the operation in any particular case must be left to the judgment of the 
practitioner. A fully-dilated os, with membranes unruptured, so that 
version could be performed by the combined method without the intro- 
duction of the hand into the uterus, would be unquestionably the most 
favorable state. If it be not deemed proper to resort to it, all that can 
be done is to endeavor to save the cord from pressure as much as possible 
by one or other of the methods already mentioned. 




Eraun's Apparatus for 
Replacing the Cord. 



PROLONGED AND PRECIPITATE LABORS. 337 



CHAPTER IX. 

PBOLONGED AND PKECIPITATE LABOKS. 

Dystocia arising from Defective or Irregular Action of the Uterus. — 
Among the difficulties connected with parturition there are none of more 
frequent occurrence, and none requiring more thorough knowledge of 
the physiology and pathology of labor, than those arising from deficient 
or irregular action of the expulsive powers. The importance of study- 
ing this class of labors will be seen when we consider the numerous and 
very diverse causes which produce them. 

Evil Effects of Prolonged Labor. — That the mere prolongation of labor 
is in itself a serious thing is becoming dailv more and more an acknow- 
ledged axiom of midwifery practice ; and that this is so is evident when 
we contrast the statistical returns of such institutions as the Rotunda 
Lying-in Hospital of late years with those which were published some 
twenty or thirty years ago. It may be fairly assumed that the practice 
of the distinguished heads of that well-known school represents the most 
advanced and scientific opinion of the day. When we find that less 
than thirty years ago the forceps were not used more than once in 310 
labors, while, according to the report for 1873, the late Master applied 
them once in 8 labors, it is apparent how great is the change which has 
taken place. 

Causes of Prolonged Labor. — Labor may be prolonged from an 
immense number of causes, the principal of which will require separate 
study. Some depend simply on defective or irregular action of the 
uterus ; others act by opposing the expulsion of the child, as, for exam- 
ple, undue rigidity of the parturient passages, tumors, bony deformity, 
and the like. Whatever the source of delay, a train of formidable 
symptoms arc developed which are fraught with peril both to the mother 
and the child. As regards the mother, they vary much in degree and 
in the rapidity with which they become established. In many cases, in 
which the action of the uterus is slight, it may be long before serious 
results follow; while in others, in which a strongly-acting organ is 
exhausting itself in futile endeavors to overcome an obstacle, the worst 
signs of protraction may come on with comparative rapidity. 

The Influence of the stage of Labor in Protraction. — The stage of 
labor in which delay occurs has a marked effecl in the production of 
untoward symptoms. It is a well-established fact that prolongation i> 
of comparatively .-mall consequence to either the mother or child in the 

firsl Stage, when the membranes are still intact, and when the sofl parte 

of the mother, as well as the body of the child, are protected l>v the li<| 

uor amnii from injurious pressure; whereas if the membranes have rup- 
tured, prolongation becomes of the utmost Importance t<> both as -<>"n ;i- 
the head has entered the pelvis, when the uterus is strongly excited bj 
reflex stimulation, when the maternal -oh parts are exposed t«> continu- 

22 



338 LABOR. 

ous pressure, and when the tightly-contracted uterus presses firmly on 
the foetus and obstructs the placental circulation. It is in reference to 
the latter class of cases that the change of practice already alluded to 
has taken place, with the most beneficial results both to the mother and 
child. 

It must not be assumed, however, that prolongation of labor is never 
of any consequence until the second stage has commenced. The fallacy 
of such an opinion was long ago shown by Simpson, who proved in the 
most conclusive way that both the maternal and foetal mortality were 
greatly increased in proportion to the entire length of the labor; and all 
practical accoucheurs are familiar with cases in Avhich symptoms of 
gravity have arisen before the first stage is concluded. Still, relatively 
speaking, the opinion indicated is undoubtedly correct. 

In the present chapter we have to do only with those causes of delay 
connected with the expulsive powers. Inasmuch, however, as the 
injurious effects of protraction are similar in kind, whatever be the 
cause, it will save needless repetition if we consider, once for all, the 
train of symptoms that arise whenever labor is unduly prolonged. 

Delay in the First Stage. — As long as the delay is in the first stage 
only, with rare exceptions no symptoms of real gravity arise for a length 
of time, it may be even for days. There is often, however, a partial ces- 
sation of the pains, which in consequence of temporary exhaustion of 
nervous force may even entirely disappear for many consecutive hours. 
Under such circumstances, after a period of rest, either natural or pro- 
duced by suitable sedatives, they recur with renewed vigor. 

Symptoms of Protraction in the Second Stage. — A similar temporary 
cessation of the pains may often be observed after the head has passed 
through the os uteri, to be also followed by renewed vigorous action 
after rest. But now any such irregularity must be much more anxiously 
watched. In the majority of cases any marked alteration in the force 
and frequency of the pains at this period indicates a much more serious 
form of delay, which in no long time is accompanied by grave general 
symptoms. The pulse begins to rise, the skin to become hot and dry, 
the patient to be restless and irritable. The longer the delay and the 
more violent the efforts of the uterus to overcome the obstacle, the more 
serious does the state of the patient become. The tongue is loaded with 
fur, and in the worst cases dry and black ; nausea and vomiting often 
become marked ; the vagina feels hot and dry, the ordinary abundant 
mucous secretion being absent ; in severe cases it may be much swollen, 
and if the presenting part be firmly impacted a slough may even form. 
Should the patient still remain undelivered, all these symptoms become 
greatly intensified : the vomiting is incessant, the pulse is rapid and 
almost imperceptible, low muttering delirium supervenes, and the patient 
eventually dies with all the worst indications of profound irritation and 
exhaustion. 

So formidable a train of symptoms, or even the slighter degrees of 
them, should never occur in the practice of the skilled obstetrician ; and 
it is precisely because a more scientific knowledge of the process of par- 
turition has taught the lesson that under such circumstances prevention is 
better than cure, that earlier interference lias become so much more the rule. 



PROLONGED AND PRECIPITATE LABORS. .339 

Those who taught that nothing should be done until nature had had 
every possible chance of effecting delivery, and who therefore allowed 
their patients to drag on in many weary hours of labor, at the expense 
of great exhaustion to themselves and imminent risk to their offspring, 
made much capital out of the time-honored maxim that " Meddlesome 
midwifery is bad." When this proverb is applied to restrain the rash 
interference of the ignorant, it is of undeniable value ; but when it is 
quoted to prevent the scientific action of the experienced, Avho know pre- 
cisely when and why to interfere, and who have acquired the indispen- 
sable mechanical skill, it is sadly misapplied. 

State of the Uterus in Protracted Labor. — The nature of the pains and 
the state of the uterus in cases of protracted labor are peculiarly worthy 
of study, and have been very clearly pointed out by Dr. Braxton 
Hicks. 1 He shows that when the pains have apparently fallen off and 
become few and feeble, or have entirely ceased, the uterus is in a state 
of continuous or tonic contraction, and that the irritation resulting from 
this is the chief cause of the more marked symptoms of powerless labor. 
If in a case of the kind the uterus be examined by palpation, it will be 
found firmly contracted between the pains. The correctness of this 
observation is beyond question, and it will no doubt often be an import- 
ant guide in treatment. Under such circumstances instrumental inter- 
ference is imperatively demanded. 

Conditions and Causes affecting the Expulsive Powers. — In consider- 
ing the causes of protracted labor it will be well first to discuss those 
which affect the expulsive powers alone, leaving those depending on 
morbid states of the passages for future consideration ; bearing in mind, 
however, that the results, as regards both the mother and the child, are 
identical, whatever may be the cause of delay. 

Constitution of the Patient. — The general constitutional state of the 
patient may materially influence the force and efficiency of the pains. 
Thus, it not unfrequently happens that they are feeble and ineffective in 
women of very weak constitution or who are much exhausted by debil- 
itating disease. Cazeaux pointed out that the effects of such general 
conditions an; often more than counterbalanced by flaccidity and want 
of resistance of the tissues, so that there is less obstacle to the passage 
of the child. Thus, in phthisical patients reduced to the last stage of 
exhaustion labor is not unfrequently surprisingly easy. 

Influence of Tropical Climates, — Long residence in tropical climates 
causes uterine inertia, in consequence of the enfeebled nervous power it 
produces. It is a common observation that European residents in India 
are peculiarly apt to suffer from post-partum hemorrhage from t lo- 
calise. The general mode of life of patients has an unquestionable 
effect ; and it is certain that deficient and irregular uterine action is more 
common in women of the higher ranks of society, who lead Luxurious, 
enervating lives, than in women whose habits are of a more healthy 
character. 

Frequent ChUdbearing. — Tyler Smith lays much stress on frequent 
childbearing as a cause of inertia, pointing out that a litems winch has 
been very frequently subjected to the changes connected with pregnancy 

1 Obst. Trans., vol. i \. 



340 LABOR. 

is unlikely to be in a typically normal condition. It is doubtful, how- 
ever, whether the uterus of a perfectly healthy woman is affected in this 
way ; certainly, if childbearing had undermined her general health the 
labors are likely to be modified also. 

Age of Patient. — Age has a decided effect. In the very young the 
pains are apt to be irregular, on account of imperfect development of 
the uterine muscle. Labor taking place for the first time in women 
advanced in life is also apt to be tedious, but not by any means so inva- 
riably as is generally believed. The apprehensions of such patients are 
often agreeably falsified, and where delay does occur it is probably more 
often referable to rigidity and toughness of the parturient passages than 
to feebleness of the pains. 

Disorders of the Intestines. — Morbid states of the primse vise fre- 
quently cause irregular, painful, and feeble contractions. A loaded 
state of the rectum has a remarkable influence, as evidenced by the sud- 
den and distinct change in the character of the labor which often follows 
the use of suitable remedies. Undue distension of the bladder may act 
in the same way, more especially in the second stage. When the urine 
has been allowed to accumulate unduly, the contraction of the accessory 
muscles of parturition often causes such intense suffering, by compress- 
ing the distended viscus, that the patient is absolutely unable to bear 
down. Hence the labor is carried on by uterine contractions alone, 
slowly and at the expense of much suffering. A similar interference 
with the action of the accessory muscles is often produced by other 
causes. Thus, if labor comes on when the patient is suffering from 
bronchitis or other chest disease, she may be quite unable to fix the chest 
by a deep inspiration, and the diaphragm and other accessory muscles 
cannot act. In the same way they may be prevented from acting when 
the abdomen is occupied by an ovarian tumor or by ascitic fluid. 

Mental conditions have a very marked effect, This is so commonly 
observed that it is familiar to the merest beginner in midwifery practice. 
The fact that the pains often diminish temporarily on the entrance of 
the accoucheur is known to every nurse ; and so also undue excitement, 
the • presence of too many people in the room, overmuch talking, have 
often the same prejudicial effect. Depression of mind, as in unmarried 
women, and fear and despondency in women who have looked forward 
with apprehension to their labor, are also common causes of irregular 
and defective action. 

Excessive Amount of Liquor Amnii. — Undue distension of the uterus 
from an excessive amount of liquor amnii not unfrequently retards the 
first stage by preventing the uterus from contracting efficiently. When 
this exists, the pains are feeble and have little effect in dilating the cer- 
vix beyond a certain degree. This cause may be suspected when undue 
protraction of the first stage is associated with an unusually large size 
and marked fluctuation of the uterine tumor, through which the foetal 
limbs cannot be made out on palpation. On vaginal examination the 
lower segment of the uterus will be found to be very rounded and prom- 
inent, while the bag of membranes will not bulge through the os during 
the acme of the pain. 

Malpositions of the Uterus. — A somewhat similar cause is undue ob- 



PROLONGED AND PRECIPITATE LABORS. 341 

liquity of the uterus, which prevents the pains acting to the best mechan- 
ical advantage and often retards the entry of the presenting part into the 
brim. The most common variety is anteversion, resulting from undue 
laxity of the abdominal parietes, which is especially found in women 
who have borne many children. Sometimes this is so excessive that the 
fundus lies over the pubes, and even projects downward toward the 
patient's knees. The consequence is, that when labor sets in, unless cor- 
rective means be taken, the pains force the head against the sacrum, 
instead of directing it into the axis of the pelvic inlet. Another com- 
mon deviation is lateral obliquity, a certain degree of which exists in 
almost all cases, but sometimes it occurs to an excessive degree. Either 
of these states can readily be detected by palpation and vaginal examina- 
tion combined. In the former the os may be so high up and tilted so 
far backward that it may be at first difficult to reach it at all. 

Irregular and Sjxtsmodie Pains. — Besides being feeble, the uterine 
contractions, especially in the first stage, are often irregular and spas- 
modic, intensely painful, but producing little or no effect on the progress 
of the labor. This kind of case has been already alluded to in treating 
of the use of anaesthetics (p. 295), and is very common in highly-nervous 
and emotional women of the upper classes. Such irregular contractions 
do not necessarily depend on mental causes alone, and they are often 
produced by conditions producing irritation, such as loaded bowels, too 
early rupture of the membranes, and the like. Dr. Trenholme of Mon- 
treal 1 believes that such irregular pains most frequently depend on 
abnormal adhesions between the decidua and the uterine walls, which 
interfere with the proper dilatation of the os, and he has related some 
interesting cases in support of this theory. 

Treatment. — The mere enumeration of these various causes of protracted 
labor will indicate the treatment required. Some of them, such as the 
constitutional state of the patient, age, or mental emotion, it is of course 
beyond the power of the practitioner to influence or modify ; but in 
every case of feeble or irregular uterine action a careful investigation 
should be made with a view of seeing if any removable cause exist. 
For example, the effect of a large enema when we suspect the existence 
of a loaded rectum is often very remarkable, the pains frequently almost 
immediately changing in character and a previously lingering labor 
being rapidly terminated. 

Excessive distension of the uterus can only be treated by artificial evac- 
uation of the liquor amnii ; and after this is done the character of the 
pains often rapidly changes. This expedient is indeed often of consider- 
able value in cases in which the cervix has dilated to a certain extent, 
but in which no further progress is made, especially if the bag of mem- 
branes does not protrude through the os during the pains, and the cer- 
vix itself is soft and apparently readily dilatable. I Inder such circum- 
stances rupture of the membranes, even before the os is fully dilated, is 
often very useful. 

Adherent Membranes. — If we have reason to suspect morbid adhe- 
sions between the membranes and the uterine walls, an endeavor musl be 
made to separate them by sweeping the finger or a flexible catheter round 

1 Obd. Trans., 1873. 



342 LABOR. 

the internal margin of the os or puncturing the sac. The former expedi- 
ent has been advocated by Dr. Inglis x as a means of increasing the pains 
when the first stage is very tedious, and I have often practised it with 
marked success. Trenholme's observation affords a rationale of its 
action. The manoeuvre itself is easily accomplished, and, provided the 
os be not very high in the pelvis, does not give any pain or discomfort 
to the patient. 

Uterine Deviations. — Attention should always be paid to remedying 
any deviations of the uterus from its proper axis. If this be lateral, 
the proper course to pursue is to make the patient lie on the opposite 
side to that toward which the organ is pointing. In the more common 
anterior deviation she should lie on her back, so that the uterus may 
gravitate toward the spine, and a firm abdominal bandage should be 
applied. This prevents the organ from falling forward, while its pres- 
sure stimulates the muscular fibres to increased action ; hence it is often 
very serviceable when the pains are feeble, even if there be no anteversion. 

Temporary Exhaustion. — In a frequent class of cases, especially in the 
first stage, the pains diminish in force and frequency from fatigue, and 
the indication then is to give a temporary rest, after which they recom- 
mence with renewed vigor. Hence an opiate, such as 20 minims of 
Battley's solution, which often acts quickest when given in the form 
of enema, is frequently of the greatest possible value. If this secure a 
few hours' sleep, the patient will generally awake much refreshed and 
invigorated. It is important to distinguish this variety of arrested pain 
from that dependent on actual exhaustion • and this can be done by 
attention to the general condition of the patient, and especially by 
observing that the uterus is soft and flaccid in the intervals between the 
pains, and that there is none of the tonic contraction indicated by per- 
sistent hardness of the uterine parietes. When the pains are irregular, 
spasmodic, and excessively painful without producing any real effect, 
opiates are also of great service ; and it is under such circumstances that 
chloral is especially valuable. 

Oxytocic Remedies. — Still, a large number of cases will arise in which 
the absence of all removable causes has been ascertained and in which 
the pains are feeble and ineffective. We must now proceed to discuss 
their management. The fault being the want of sufficient contraction, the 
first indication is to increase the force of the pains. Here the so-called 
oxytocic remedies come into action ; and although a large number of 
these have been used from time to time, such as borax, cinnamon, qui- 
nine, and galvanism, practically the only one on which reliance is gener- 
ally placed is the ergot of rye. 

Ergot of Rye. — This has long been the favorite remedy for deficient 
uterine action, and it is a powerful stimulant of the uterine fibres. It 
has, however, very serious disadvantages, and it is very questionable 
whether the risks to both mother and child do not more than counter- 
balance any advantages attending its use. The ergot is given in doses 
of 15 or 20 grains of the freshly-powdered drug infused in warm water, 
or in the more convenient form of the liquid extract in doses of from 20 
to 30 minims, or, still better, in the form of ergotin injected hypodermic- 

1 Sydenham Society's Year- Book, 1869. 



PROLONGED AND PRECIPITATE LABORS. 343 

ally, 3 to 4 minims of the hypodermic solution being used for the pur- 
pose. In about fifteen minutes after its administration the pains gener- 
ally increase greatly in force and frequency, and if the head be low in 
the pelvis, and if the soft parts offer no resistance, the labor may be 
rapidly terminated. 

Objections to its Use. — Were its use always followed by this effect there 
would be little or no objection to its administration. The pains, how- 
ever, are different from those of natural labor, being strong, persistent, 
and constant. Its effect, indeed, is to produce that very state of tonic 
and persistent uterine contraction which has been already pointed out as 
one of the chief dangers of protracted labor. Hence, if, from any cause, 
the exhibition of the drug be not followed by rapid delivery, a condition 
is produced which is serious to the mother, and which is extremely peril- 
ous to the child, on account of the tonic contraction of the muscular 
fibres obstructing the utero-placental circulation. Dr. Hardy found that 
soon the foetal pulsations fall to 100, and if delivery be long delayed 
they commence to intermit. He also observed that when this occurred 
the child was always born dead, and found that the number of stillborn 
children after ergot has been exhibited was very large, for out of 30 
cases in which he gave it in tedious labor, only 10 of the children were 
born alive. Xor is its use by any means free from any danger to the 
mother : a not inconsiderable number of cases of rupture of the uterus 
have been attributed to its incautious use. Hence, if it is to be given 
at all, it is obvious that it must be with strict limitations and after care- 
ful consideration. It is worthy of note that in the Rotunda Hospital 
in Dublin the use of ergot as an oxytocic before delivery has been pro- 
hibited by the present Master. 

Limitations to its Use. — The cardinal point to remember is, that it is 
absolutely contraindicated unless the absence of all obstacles to rapid 
delivery has been ascertained. Hence, it is only allowable when the 
first stage is over and the os fully dilated; when the experience of for- 
mer labors has proved the pelvis to be of ample size ; and when the 
perineum is soft and dilatable. Perhaps, as has been suggested, the 
administration of small doses of from 5 to 10 minims of the liquid 
extract every ten minutes until more energetic action set in might obvi- 
ate some of these risks. 

Quinine as an Oxytocia. — The use of quinine as an oxytocic deserves 
much more attention than it has generally received. I frequently employ 
it in lingering labor with marked benefit, and it docs not seem to have any 
of the bad effects of ergot. According to the observations of Dr. Albert 
H. Smith, in 4'2 cases of parturition it presented the following peculiar 
characteristics : 

It has no power in itself to excite uterine contraction-, but simply 
act- a- a general stimulant and promoter of vital energy and functional 
activity. 

In normal labor at full term its administration in a dose of I .", grains 
is usually followed in as many minutes by a decided Increase in the force 
and frequency of the uterine contractions, changing in some instances a 
tediotts, exhausting labor into one of rapid energy, advancing to an early 
completion. 



344 LABOR. 

It promotes the permanent tonic contraction of the uterus after the 
expulsion of the placenta, women that had flooded in former labors escap- 
ing entirely, there not having been an instance of post-partum hemorrhage 
in the whole 42 cases. 

It also diminishes the lochial flow where it had been excessive in for- 
mer labors, the change being remarked upon by the patients, and conse- 
quently lessens the severity of the after-pains. 

Cinchonism is very rarely observed as an effect of large doses in par- 
turient women. 1 

Use of the Faradic Current. — The faradic current applied on either 
side of the uterine tumor, midway between the anterior-superior spine 
of the ilium and the umbilicus, has recently been strongly recommended 
by Dr. Kilner, 2 not only as a means of increasing uterine action, but of 
alleviating the sufferings of childbirth. I have tried it in several cases, 
but am not satisfied as to its possessing the properties attributed to it. 

Manual Pressure as a Means of Increasing the Uterine Contractions. — 
If Ave had no other means of increasing defective uterine contractions at 
our disposal, and if the choice lay only between the use of ergot and 
instrumental delivery, there might not be so much objection to a cau- 
tious use of the drug in suitable cases. We have, however, a means of 
increasing the force of the uterine contractions so much more manage- 
able and so much more resembling the natural process that I believe it 
to be destined to entirely supersede the administration of ergot. This 
is the application of manual pressure to the uterus through the abdo- 
men — an expedient that has of late years been much used in Germany, 
and has begun to be employed in English practice. I believe, therefore, 
that ergot should be chiefly used for the purpose of exciting uterine con- 
traction after delivery, when its peculiar property of promoting tonic- 
contraction is so valuable, and that it should rarely, if at all, be employed 
before the birth of the child. 

The systematic use of uterine pressure as an oxytocic was first promi- 
nently brought under the notice of the profession by Kristeller under 
the name of " Expressio Foetus," although it has been used in various 
forms from time immemorial. Albucasis, for example, was clearly 
acquainted with its use, and referred to it in the following terms : " Cum 
ergo vides ista signa, tunc oportet, ut comprimatur uterus ejus ut descendat 
embryo velociter." There are some curious obstetric customs among vari- 
ous nations which probably arose from a recognition of its value ; as, 
for example, the mode of delivery adopted among the Kalmucks, where 
the patient sits at the foot of the bed, Avhile a woman seated behind her 
seizes her round the waist and squeezes the uterus during the pains. 
Amongst the Japanese, Siamese, North American Indians, and many 
other nations pressure, applied in various ways, is habitually used. 

Kristeller maintains that it is possible to effect the complete expulsion 
of the child by properly-applied pressure, even when the pains are 
entirely absent. Strange as this may appear to those who are not familiar 
with the effects of pressure, I believe that under exceptional circum- 
stances, when the pelvis is very capacious and the soft parts offer but 
slight resistance, it can be done. I have delivered in this way a patient 

1 Tram. Coll. Phys. PhUada., 1875, p. 183. 2 Lancet, January 1, 1881. 



PROLONGED AND PRECIPITATE LABORS. 345 

whose friends would not permit me to apply the forceps when I could 
not recognize the existence of any uterine contraction at all, the foetus 
being literally squeezed out of the uterus. It is not, however, as repla- 
cing absent pains, but as a means of intensifying and prolonging the 
effects of deficient and feeble ones, that pressure finds its best application. 

Its effects are often very remarkable, especially in women of slight 
build where there is but little adipose tissue in the abdominal walls and 
not much resistance in the pelvic tissues. If the finger be placed on the 
head while pressure is applied to the uterus, a very marked descent can 
readily be felt, and not infrequently two or three applications will force 
the head on to the perineum. There are, however, certain conditions 
when it is inapplicable, and the existence of which should contraindicate 
its use. Thus, if the uterus seem unusually tender on pressure, and, 
a fortiori, if the tonic contraction of exhaustion be present, it is inad- 
missible. So also if there be any obstruction to rapid delivery, either 
from narrowing of the pelvis or rigidity of the soft parts, it should not 
be used. The cases suitable for its application are those in which the 
head or breech is in the pelvic cavity, and the delay is simply due to a 
want of sufficiently strong expulsive action. 

Mode of Application. — It may be applied in two ways. The better 
is to place the patient on her back at the edge of the bed, and spread the 
palms of the hands on either side of the fundus and body of the uterus, 
and when a pain commences to make firm pressure during its continu- 
ance downward and backward in the direction of the pelvic inlet. As 
the contraction passes off the pressure is relaxed, and again resumed 
when a fresh pain begins. In this way each pain is greatly intensified 
and its effect on the progress of the foetus much increased. It is not 
essential that the patient should lie on her back. A useful although not 
so great amount of pressure can be applied when she is lying in the 
ordinary obstetric position on her left side, the left hand being spread 
out over the fundus, leaving the right free to watch the progress of the 
presenting part per vaginam. 

Special Value of Uterine Pressure. — The special value of this method 
of treating ineffective pains is, that the amount and frequency of the 
pressure are completely within the control of the practitioner, and are 
capable of being regulated to a nicety in accordance with the require- 
ments of eacli particular case. It has the peculiar advantage of closely 
imitating the natural means of delivery, and of being absolutely without 
risk to the child ; nor is there any reason to think that it is capable of 
injuring the mother. At least I may safely say that, out of the large 
number of eases in which I have used it, I have never seen one in 
which I had the least reason to think that it had proved hurtful. Of 
course it is essential not to use undue roughness : firm and even strong 
pressure may be employed, but that can ho done without being rough ; 
and, as its application is always intermittent, there is no time for it to 
inflict any injury on the uterine tissues. 

Pressure is specially valuable when it is desirable to intensify feeble 
pains. It may be serviceably employed when the pains are altogether 
absent to imitate and replace them, provided there be nothing hut the 
absence of a vis a tergo to prevent speedy delivery. In Buch cases an 



346 LABOR. 

endeavor should be made to imitate the pains as closely as possible by 
applying the pressure at intervals of four or five minutes, and entirely 
relaxing it after it has been applied for a few seconds. 

Change of Professional Opinion as to Instrumental Delivery. — "When 
all these means fail, we have then left the resource of instrumental aid ; 
and we have now to consider the indications for the use of the forceps 
under such circumstances. It has been already pointed out that pro- 
fessional opinion on this point has been undergoing a marked change, 
and that it is now recognized as an axiom by the most experienced 
teachers that when we are once convinced that the natural efforts are 
failing and are unlikely to effect delivery, except at the cost of long 
delay, it is far better to interfere soon rather than late, and thus prevent 
the occurrence of the serious symptoms accompanying protracted labor. 
The recent important debate on the use of the forceps at the Obstetrical 
Society of London remarkably illustrated these statements, for, while 
there was much difference of opinion as to the advisability of applying 
the forceps when the head was high in the pelvis, a class of cases not 
now under consideration, it was very generally admitted that the modern 
teaching was based on correct scientific grounds. This is, of course, 
directly opposed to the view so long taught in our standard works, in 
which instrumental interference was strictly prohibited unless all hope 
of natural delivery was at an end, and in which the commencement at 
least, if not the complete establishment, of symptoms of exhaustion was 
considered to be the only justification for the application of the forceps 
in lingering labor. 

Views of Dr. Johnston on the Use of the Forceps.— -The reasons which 
have led the late distinguished Master of the Rotunda Hospital to a 
more frequent use of the forceps are so well expressed in his report for 
1872 that I venture to quote them as the best justification for a practice 
that many practitioners of the older school will, no doubt, be inclined 
to condemn as rash and hazardous. He says : 1 " Our established rule 
is, that so long as nature is able to effect its purpose without prejudice 
to the constitution of the patient, danger to the soft parts or the life of 
the child, we are in duty bound to allow the labor to proceed ; but as 
soon as we find the natural efforts are beginning to fail, and after having 
tried the milder means for relaxing the parts or stimulating the uterus 
to increased action, and the desired effects not being produced, we con- 
sider we are in duty bound to adopt still prompter measures, and by our 
timely assistance relieve the sufferer from her distress and her offspring 
from an imminent death. "Why, may I ask, should we permit a fellow- 
creature to undergo hours of torture when we have the means of reliev- 
ing her within our reach ? Why should she be allowed to waste her 
strength and incur the risks consequent upon long pressure of the head 
on the soft parts, the tendency to inflammation and sloughing, or the 
danger of rupture, not to speak of the poisonous miasm which emanates 
from an inflammatory state of the passages, the result of tedious labor, 
and which is one of the fertile causes of puerperal fever and all its dire- 
ful effects, attributed by some to the influence of being confined in a 
large maternity, and not to its proper source — i. e. the labor being 

1 Fourth Clinical Report of the Rotunda Lying-in Hospital/or the year ending 1872. 



PROLONGED AND PRECIPITATE LABORS. 347 

allowed to continue till inflammatory symptoms appear ? The more we 
consider the benefits of timely interference and the good results which 
folio w it, the more are we induced to pursue the system we have 
adopted, and to inculcate to those we are instructing the advantages 
to be gained by such practice, both in saving the life of the child as 
well as securing the greater safety of the mother." It would be 
impossible to put the matter in a stronger or clearer light, and I feel 
confident that these views will be endorsed by all who have adopted the 
more modern practice. 

Effect of Early Interference on Infantile Mortality. — In the first edition 
of this work I used the statistics of Dr. Hamilton of Falkirk and other 
modern writers, as proving that a more frequent use of the forceps than 
had been customary diminished in a remarkable degree the infantile 
mortality. Dr. Galabin 1 has recently published an admirable paper on 
this subject, in which, by a careful criticism of these figures, he has, I 
think, proved that the conclusions drawn from them are open to doubt, 
and that the saving of infantile life following more frequent forceps 
delivery is by no means so great as I had supposed. Dr. Roper, in his 
remarks in the recent debate in the Obstetrical Society, brought forward 
some strong arguments in support of the same view. This, however, 
does not in any way touch the main points at issue referred to in the 
preceding paragraph. 

Possible Dangers attending the Use of the Forceps. — It is, of course, 
right that we should consider the opposite point of view, and reflect on 
the disadvantages which may attend the interference advocated. Here 
I should point out that I am now talking only of the use of the forceps 
in simple inertia, when the head is low in the pelvic cavity, and when 
all that is wanted is a slight vis a f route to supplement the deficient vis 
a tergo. The use of the instrument when the head is arrested high in 
the pelvis, or in cases of deformity, or before the os uteri is completely 
expanded, is an entirely different and much more serious matter, and 
does not enter into the present discussion. The chief question to decide 
is if there be sufficient risk to the mother to counterbalance that of 
delay. It will, of course, be conceded by all that the forceps in the 
hands of a coarse, bungling, and ignorant practitioner, who has not 
studied the proper mode of operating, may easily inflict serioUs damage. 
The possibility of inflicting injury in this way should act as a warning 
to every obstetrician to make himself thoroughly acquainted with Im- 
proper mode of using the instrument, and to acquire the manual skill 
which practice and the study of the mechanism of delivery will alone 
give; but it can hardly be used as an argument against its use. If* that 
were admitted, surgical interference of any kind would he tabooed, since 
there is none that ignorance and incapacity might not render dangerous. 

Assuming, therefore, that the practitioner is able to apply the forceps 
skilfully, is there any inherent danger in its use? 1 think all who dis- 
passionately consider the question must admit that in the class of cases 
alluded to the operation is so simple thai its disadvantages cannot for a 
moment be weighed against those attending protraction and it- conse- 
quences. Againsl this conclusion statistics may possibly be quoted, such 
1 Obstetrical Journal, December, L877; 



348 LABOR. 

as those of Churchill, who estimated that 1 in 20 mothers delivered by 
forceps in British practice was lost. But the fallacy of such figures is 
apparent on the slightest consideration, and by no one has this been 
more conclusively shown than by Drs. Hicks and Phillips in their paper 
on tables of mortality after obstetric operations, 1 where it is proved in 
the clearest manner that such results are due not to the treatment, but 
rather to the fact that the treatment was so long delayed. 

Impossibility of Laying down any Definite Rules for the Use of the 
Forceps. — It is quite impossible to lay down any precise rule as to when 
the forceps should be used in uterine inertia. Each case must be treated 
on its own merits and after a careful estimate of the effects of the pains. 
The rules generally taught were that the head should be allowed to rest 
at or near the perineum for a number of hours, and that interference 
was contraindicated if the slightest progress were being made. It is 
needless to say that both of these rules are incompatible with the views 
I have been inculcating, and that any rule based upon the length of 
time the second stage of labor has lasted must necessarily be misleading. 
What has to be done, I conceive, is to watch the progress of the case 
anxiously after the second stage has fairly commenced, and to be guided 
by an estimate of the advance that is being made and the character of 
the pains, bearing in mind that the risk to the mother, and still more to 
the child, increases seriously with each hour that elapses. If Ave find 
the progress slow and unsatisfactory, the pains flagging and insufficient, 
and incapable of being intensified by the means indicated, then, pro- 
vided the head be low in the pelvis, it is better to assist at once by the 
forceps, rather than to wait until we are driven to do so by the state of 
the patient. 2 

1 Ob fit. Trans., vol. xiii. 

2 It may perhaps be of interest in connection with this important topic in practical 
midwifery if I reprint a letter I published some years ago in the Medical Times and 
Gazette. An historical case, such as that of which it treats, will better illustrate the 
evil effects that may follow unnecessary delay than any amount of argument. It seems 
to me impossible to read the details of the delivery it describes without being forcibly 
struck with the disastrous results which followed the practice adopted, which, however, 
was strictly in accordance with that which, up to a quite recent date, has been consid- 
ered correct by the highest obstetric authorities : 

ON THE DEATH OF THE PRINCESS CHARLOTTE OF WALES. 

[To the Editor of the Medical Times and Gazette.] 

Sir : The letter of your correspondent, "An Old Accoucheur," regarding the death 
of the Princess Charlotte, raises a question of great interest — viz. Avhether the fatal 
result might have been averted under other treatment. The history of the case is most 
instructive, and I think a careful consideration of it leaves little room to doubt that, 
though the management of the labor was quite in accordance with the teaching of the 
day, it was entirely opposed to that of modern obstetric science. The following account 
of the labor may interest your readers, and will probably be new to most of them. It is 
contained in a letter from Dr. John Sims to the late Dr. Joseph Clarke of Dublin : 

" London, November 15, 1817. 
"My Dear Sir: I do not wonder at your wishing to have a correct statement of 
the labor of her Royal Highness the Princess Charlotte, the fatal issue of which has 
involved the whole nation in distress. You must excuse my being very concise, as I 
have been and am very much hurried. I take the opportunity of writing this in a 
lying-in chamber. Her Royal Highness's labor commenced by the discharge of the 
liquor amnii about seven o'clock on Monday evening, and the pains followed soon 
after. They continued through the night and a greater part of the next day — sharp, 



PROLONGED AND PRECIPITATE LABORS. 349 

Precipitate Labor less Common than Lingering. — Undue rapidity of 
labor is certainly more uncommon than its converse, but still it is by no 

soft, but very ineffectual. Toward the evening Sir Kichard Croft began to suspect that 
labor might not terminate without artificial assistance, and a message was despatched 
for me. I arrived at two on Wednesday morning. The labor was now advancing 
more favorably, and both Dr. Baillie and myself concurred in the opinion that it would 
not be advisable to inform her Royal Highness of my arrival. From this time to the 
end of her labor the progress was uniform, though very slow, the patient in good 
spirits, the pulse calm, and there never was room to entertain a question about the 
use of instruments. About six in the afternoon the discharge became of a green color, 
which led to a suspicion that the child might be dead ; still, the giving assistance was 
quite out of the question, as the pains now became more effectual and the labor pro- 
ceeded regularly though slowly. The child was born without artificial assistance at 
nine o'clock in the evening. Attempts were made for a good while to reanimate it by 
inflating the lungs, friction, hot baths, etc., but without effect ; the heart could not be 
made to beat even once. Soon after delivery Sir Richard Croft discovered that the 
uterus was contracted in the middle in the hour-glass form, and as some hemorrhage 
commenced, it was agreed that the placenta should be brought away by introducing 
the hand. This was done about half an hour after the delivery of the child, with more 
ease and less blood than usual. Her Royal Highness continued well for about two 
hours ; she then complained of being sick at stomach and of noise in the ears, began to 
be talkative, and her pulse became frequent ; but I understand she was very quiet after 
this, and her pulse calm. About half-past twelve o'clock she complained of severe 
pain in the chest, became extremely restless, with rapid, weak, and irregular pulse. 
At this time 1 saw her for the first time. It has been said that we had all gone to bed, 
but that is not a fact : Croft did not leave her room, Baillie retired about eleven, and I 
went to my bed-chamber and laid down in my clothes at twelve. By dissection, some 
bloody fluid (two ounces) was found in the pericardium, supposed to be thrown out in 
wticulo mortis. The brain and other organs all sound, except the right ovarium, which 
was distended into a cyst the size of a hen's egg. The hour-glass contraction of the 
uterus still visible, and a considerable quantity of blood in the cavity of the uterus — 
but those present dispute about the quantity, so much as from twelve ounces to a pound 
.and a half — her uterus extending as high as her navel. The cause of her Royal High- 
ness's death is certainly somewhat obscure ; the symptoms were such as attend death 
from hemorrhage, but the loss of blood did not seem to be sufficient to account for a 
fatal issue. It is possible that the effusion into the pericardium took place earlier than 
was supposed, and it does not seem to be quite certain that this might not be the cause. 
That 1 did not see her Royal Highness more early was awkward, and it would have 
been better that I had been introduced before the labor was expected ; and it should 
have been understood that when labor came on I should be sent to without waiting to 
know whether a consultation was necessary or not. I thought so at the time, but I 
could not propose such an arrangement to Croft. But this is entirely enlre noux. I am 
glad to hear that your son is well, and, with all my family, wish to be remembered to 
him. We were happy to hear that he was agreeably married. 

" 1 remain, my dear doctor, 

" Ever yours, most truly. 

"Jonx Sims, M. D. 

"This letter is confidential, as perhaps I might be blamed for writing any particulars 
without the permission of Prince Leopold." 

What are the facts here shown? Here was a delicate young woman prepared for 
the trial before her, as Baron Stockmar tells us, by "lowering the organic strength of 
the mother by bleeding, aperients, and low diet," who was allowed to go on in linger- 
ing, feeble labor for no less than fifty-two hours after the escape of the liquor amnii ! 
Such was the groundless dread of instrumental interference then prevalent that, 
although the case dragged on its weary length with feeble, ineffectual pains, even 
now and then increasing a little in intensity and then falling off again, it is Stated 
''there never was room to entertain a question aboul the use of instruments^' and 

even "when the discharge became of a green color still, the giving assistant 

was quite out of the question" ! Can any reasonable man doubt thai iT the forceps had 
been employed hours and hours befon — say on Tuesday, when the pains fell off — the 
result would probably have been very different, and that the life of the child, destroyed 
by the enormously-prolonged second Btage, would have been saved/ It must be remem- 
bered that early on Tuesday morning delivery was expected, bo thai the head must 



350 LABOR. 

means of unfrequent occurrence. Most obstetric works contain a for- 
midable catalogue of evils that may attend it, such as rupture of the 
cervix, or even of the uterus itself, from the violence of the uterine 
action ; laceration of the perineum from the presenting part being driven 
through before dilatation has occurred ; fainting from the sudden empty- 
ing of the uterus ; hemorrhage from the same cause. With regard to the 
child, it is held that the pressure to which it is subjected, and sudden 
expulsion while the mother is in the erect position, may prove injurious. 
Without denying that these results may possibly occur now and again, 
in the majority of cases over-rapid labor is not attended with any evil 
effects. 

Precipitate labor may generally be traced to one of two conditions, or 
to a combination of both : excessive force and rapidity of the pains or 
unusual laxity and want of resistance of the soft parts. The precise 
causes inducing these it is difficult to estimate. In some cases the 
former may depend on an undue amount of nervous excitability, and 
the latter on the constitutional state of the patient, tending to relaxation 
of the tissues. 

Whatever the cause, the extreme rapidity of labor is occasionally 
remarkable, and one strong pain may be sufficient to effect the expul- 
sion of the child with little or no preliminary warning. I have known 
a child to be expelled into the pan of a water-closet, the only previous 
indication of commencing labor being a slight griping pain, which led 
the mother to fancy that an action of the bowels was about to take place. 
More often there is what maybe described as a storm of uterine contrac- 
tions, one pain following the other with great intensity until the foetus is 
expelled. The natural effect of this is to produce a great amount of 
alarm or nervous excitement, which of itself forms one of the worst 
results of this class of labor. It is under such circumstances that teni- 

then have been low in the pelvis (vide Stockmar's Memoirs, vol. i. p. 63). It would be 
difficult to find a case which more forcibly illustrates the danger of delay in the second 
stage of labor. Then what follows? The uterus, exhausted by the lengthy efforts it 
should have been spared, fails to contract effectually, nor do we hear of any attempts to 
produce contraction by pressure. The relaxed organ becomes full of clots, extending 
up to the umbilicus, and all the most characteristic symptoms of concealed post-partum 
hemorrhage develop themselves. She complained " of being sick at stomach and of 
noise in her ears — began to be talkative, and her pulse became frequent." Before long 
other symptoms came on, graphically described by Baron Stockmar, and which seem 
to point to the formation of a clot in the heart and pulmonary arteries — a most likely 
occurrence after such a history. " Baillie sent me word that he wished me to see the 
princess. . I hesitated, but at last went with him. She was suffering from spasms of 
the chest and difficulty of breathing, in great pain, and very restless, and threw her- 
self continually from one side of the bed to the other, speaking now to Baillie, now to 
( 'roft. Baillie said to her, ' Here comes an old friend of yours.' She held out her left 
hand to me hastily, and pressed mine warmly twice. I felt her pulse ; it was going- 
very fast — the beats now strong, now feeble, now intermittent." 

Here was evidently something different from the exhaustion of hemorrhage ; and no 
one who has witnessed a case of pulmonary obstruction can fail to recognize in this 
account an accurate delineation of its dreadful symptoms. 

Surely this lamentable story can only lead to the conclusion that the unhappy and 
gifted princess fell a victim to the dread of that bugbear, "meddlesome midwifery," 
which has so long retarded the progress of obstetrics. 

I am, etc., 

W. S. Playfair. 

Curzon Street, Mayfaif, W., November Jit, 1872. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 351 

porary mania occurs, produced by the intensity of the suffering, under 
which the patient may commit acts, her responsibility for which may 
fairly be open to question. 

Treatment. — Little can be done in treating undue rapidity of labor. 
We can, to some extent, modify the intensity of the pains by urging the 
patient to refrain from voluntary efforts and to open the glottis by cry- 
ing out, so that the chest may no* longer be a fixed point for muscular 
action. Opiates have been advised to control uterine action, but it is 
needless to point out that in most cases there is no time for them to take 
effect. Chloroform will often be found most valuable, from the rapidity 
with which it can be exhibited ; and its' power of diminishing uterine 
action, which forms one of its chief drawbacks in ordinary practice, will 
here prove of much service. 



CHAPTER X. 

LABOE OBSTRUCTED BY FAULTY CONDITION OF THE SOFT PARTS. 

Rigidity of the Cervix a Frequent Cause of Protracted Labor. — One 
of the most frequent causes of delay in the first stage of labor is rigidity 
of the cervix uteri, which may depend on a variety of conditions. It is 
often produced by premature escape of the liquor amnii, in consequence 
of which the fluid wedge which is nature's means of dilating the os is 
destroyed, and the hard presenting part is consequently brought to bear 
directly upon the tissues of the cervix, which are thus unduly irritated 
and thrown into a state of spasmodic contraction. At other times it 
may be due to constitutional peculiarities, among which there is none so 
common as a highly nervous and emotional temperament, which renders 
the patient peculiarly sensitive to her sufferings and interferes with the 
harmonious action of the uterine fibres. The pains in such cases cause 
intense agony, are short and cramp-like in character, but have little or 
no effect in producing dilatation, the OS often remaining for many hours 
without any appreciable alteration, its edge- being thin and tightly 
stretched over the head. Less often — and this Is generally met with in 
stout, plethoric women — the edges of the OS are thick and tough. 

Effects. — The effects of prolongation of labor from this cause will 
vary much under different circumstances. If the liquor amnii be pre- 
maturely evacuated, the presenting part presses directly upon the cervix, 
and the case is then practically the same as if the labor were in the 
second stage. Hence, grave symptoms may soon develop themselves, 
and early interference may be imperatively demanded. If the mem- 
branes be unruptured, delay will be of comparatively little moment, and 
considerable time may elapse without serious detriment to either the 
mother or child. 

Treatment. — The treatment will naturally vary much with the cause 



352 LABOR. 

and the state of the patient. In the majority of cases, especially if the 
membranes be still intact, patience and time are sufficient to overcome 
the obstacle ; but it is often in the power of the accoucheur materially to 
aid dilatation by appropriate management. Sometimes nature overcomes 
the obstruction by lacerating the opposing structures, and cases are on 
record in which even a complete ring of the cervix has been torn off and 
come away before the head. 

Many remedies have been recommended for facilitating dilatation, 
some of which no doubt act beneficially. Among those most frequently 
resorted to was venesection, and with it was generally associated the 
administration of nauseating doses of tartar emetic. Both of these acted 
by producing temporary depression, under which the resistance of the 
soft part was lessened. They probably answer best in cases in which 
there was a rigid and tough cervix ; and they might prove serviceable 
even yet in stout, plethoric women of robust frame. Practically, they 
are now seldom if ever employed, and other and less debilitating reme- 
dies are preferred. The agent, par excellence, which is most serviceable 
is chloral, which is of special value in the more common cases in which 
rigidity is associated with spasmodic contraction of the muscular fibres 
of the cervix. Two or three doses of 15 grains, repeated at intervals 
of twenty minutes, are often of almost magical efficacy, the pains becom- 
ing steady and regular and the os gradually relaxing sufficiently to allow 
the passage of the head. Should the chloral be rejected by the stomach, 
it may be satisfactorily administered per rectum. Chloroform acts much 
in the same way, but on the whole less satisfactorily, its effects being 
often too great ; while the peculiar value of chloral is its influence in 
promoting relaxation of the tissues without interfering with the strength 
of the pains. 

Local Means of Treatment. — Various local means of treatment may 
be also advantageously used. One is the warm bath, which is much 
used in France. It is of unquestionable value where there is mere 
rigidity, and may be used either as an entire bath or as a hip-bath, in 
which the patient sits from twenty minutes to half an hour. The objec- 
tion is the fuss and excitement it causes, and for this reason it is an 
expedient seldom resorted to in this country. A similar effect is pro- 
duced, and much more easily, by a douche of tepid water upon the cer- 
vix. This can be very easily administered, the pipe of a Higginson's 
syringe being guided up to the cervix by the index finger of the right 
hand, and a stream of water projected against it for five or ten minutes. 
Smearing the os with extract of belladonna is advised by continental 
authorities, but its effects are more than doubtful. Horton 1 advocates 
the injection into the tissue of the cervix of ^- of a grain of atropine 
by means of a hypodermic syringe, and speaks very favorably of the 
practice. 

Artificial Dilatation. — Artificial dilatation of the cervix by the finger 
has often been recommended, and has been the subject of much discus- 
sion, especially in the Edinburgh school, where it was formerly commonly 
employed. It is capable of being very useful, but it may also do much 
injury when roughly and injudiciously used. The class of cases in which 

1 Amer. Journ. of Obst., July, 1878. 



OBSTRUCTlOX FROM COXDITIOX OF SOFT PARTS. 353 

it is most serviceable are those in which the liquor amnii has been long 
evacuated, and in which the head, covered by the tightly-stretched cer- 
vix, has descended low into the pelvic cavity. Under these circum- 
stances, if the finger be passed gently within the os during a pain, and 
its margin pressed upward and over the head, as it were, while the con- 
traction lasts, the progress of the case may be materially facilitated. 
This manoeuvre is somewhat similar to that which has been already 
spoken of when the anterior lip of the cervix is caught between the head 
and the pubic bone, and if properly performed I believe it to be quite 
safe and often of great value. It is not, however, well adapted for those 
cases in which the membranes are still intact, or in which the os remains 
undilated when the head is still high in the pelvis. When there is much 
delay under these conditions, and interference of some kind seems called 
for, the dilatation may be much assisted by the use of caoutchouc dila- 
tors, described in the chapter on the induction of premature labor, which 
imitate nature's method of opening up the os, and also act as a direct 
stimulant to uterine contraction. But it should be remembered that it 
is precisely in such cases that delay is least prejudicial. If, however, 
the os be excessively long in opening, its dilatation may be safely and 
efficiently promoted by passing within it, and distending with water, 
one of the smallest-sized bags • and after this has been in position 
from ten to twenty minutes it may be removed and a larger one 
substituted. 

Rigidity depending upon Organic Causes. — Every now and again 
we meet with cases in which the obstacle depends upon organic changes 
in the cervix, the most common of which are cicatricial hardening from 
former lacerations, hypertrophic elongation of the cervix from disease 
antecedent to pregnancy, or even agglutination and closure of the os 
uteri. Cicatrices are generally the result of lacerations during former 
labors. They implicate a portion only of the cervix, which they render 
hard, rigid, and undilatable, while the remainder has its natural soft- 
m 38. They can readily be made out by the examining finger. A some- 
what similar but much more formidable obstruction is occasionally met 
with in cases of old-standing hypertrophic elongation of the cervix, 
which is generally associated with prolapse. In most cases of this kind 
the cervix becomes softened during pregnancy, so that dilatation occurs 
without any unusual difficulty. But this does not always happen. A 
good example is related by Mr. Roper in the seventh volume of (he 
Obstetrical Transactions, in which such a cervix formed an almost insu- 
perable obstacle to the passage of the child. 

Carcinoma of the cervix uteri, which produces extensive thickening 
and induration of its tissues, and even advanced malignant disease of the 
uterus, is no bar to conception. The relations of malignant disease to 
pregnancy and parturition have recently been well studied by Dr. Her- 
man. 1 He concludes that cancer renders the patient inapt to conceive, 
but that when pregnancy does occur there is a tendency to the intra- 
uterine death and premature expulsion of the foetus, and the growth <»i' 
the cancer is accelerated. When delivery Is accomplished naturally, 
there is generally expansion of the cervix by assuring of it- tissue, 

l Ob*t. Trans., vol. xx. p. 191. 
23 



354 LABOR. 

but the harder forms of cancer may form an insuperable obstacle to 
delivery. 

Occlusion of the Os. — Agglutination of the margins of the os uteri is 
occasionally met with, and must, of course, have occurred after concep- 
tion. It is generally the result of some inflammatory affection of the 
cervix during the early months of gestation ■ and I have known it to recur 
in the same woman in two successive pregnancies. Usually it is not 
associated with any hardness or rigidity, but the entire cervix is 
stretched over the presenting part, and forms a smooth covering, in 
which the os may only exist as a small dimple and may be very difficult 
to detect at all. Occlusion of the os uteri from inflammatory change 
sometimes so alters the cervix that no sign of the original opening 
can be discovered ; and in two such instances the Csesarean operation 
has been performed in the United States, by which the women were 
saved. 1 

Treatment — Any of these mechanical causes of rigidity may at first be 
treated in the same way as the more simple eases ; and with patience, 
the use of chloral and chloroform, and of the fluid dilators, sufficient 
expansion to permit the passage of the head will often take place. But 
if these methods produce no effect, and symptoms of constitutional irri- 
tation are beginning to develop themselves, other and more radical means 
of overcoming the obstruction may be required. 

Incision of the Cervix. — Under such circumstances incision of the cer- 
vix may be not only justifiable, but essential, and it frequently answers 
extremely well. On the Continent it is resorted to much more fre- 
quently and earlier than in this country, and with the most beneficial 
results. The operation offers no difficulties. The simplest way of per- 
forming it is to guard the greater portion of the blade of a straight, 
blunt-pointed bistoury by wrapping lint or adhesive plaster round it, 
leaving about half an inch cutting edge toward its point. This is 
guided to the cervix on the under surface of the index finger, and three 
or four notches are cut in the circumference of the os to about the depth 
of a quarter of an inch. Very generally, especially when the obstruc- 
tion is only due to old cicatrices, the pains will now speedily effect com- 
plete expansion, which may be very advantageously aided by applying 
the hydrostatic dilators. When the obstruction is due to carcinomatous 
infiltration or inflammatory thickening, the case is much more compli- 
cated, and will painfully tax the resources of the accoucheur. If it is 
possible, the disease should be removed as much as can be safely done 
during pregnancy, which should also be brought to an end before the 
full period. During labor, incisions should form a preliminary to any 
subsequent proceedings that may be necessary, as they are, at the worst, 
not likely to increase in the least the risk the patient has to run, and 
they may possibly avert more serious operations. In the case of malig- 
nant disease the risk of serious hemorrhage, from the great vascularity 
of the tissues, must not be forgotten, and,- if necessary, means must be 
taken to check this by local styptics, such as perchloride of iron. If 
incision fail and the state of the patient demands speedy delivery, the 
forceps may be applied ; and Herman thinks they are, as a rule, better 

1 Harris's note to second American edition. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 355 

than turning. He also maintains that there is little difference in the 
risk to the mothers between craniotomy and the Cesarean section, and 
that the possibility of saving the child in cases in which incisions have 
failed should induce us to prefer the latter. 

Application of the Forceps icithin the Cervix. — Before performing 
craniotomy, when the os is sufficiently open, a cautious application of 
the forceps is quite justifiable. Steady and careful downward traction, 
combined with digital expansion, has often enabled a head to pass with 
safety through an os that has resisted all other means of dilatation, and 
the destruction of the child has thus been avoided. If, indeed, the os 
appear to be dilatable, this procedure may advantageously be adopted 
before incision, and, as a matter of fact, it is commonly practised in the 
Rotunda Hospital. An operation involving, beyond doubt, of itself 
some risk, and requiring considerable operative dexterity, should natu- 
rally not be lightly and inconsiderately undertaken. But when it is 
remembered that the alternative is the destruction of the child, the risk 
of exhaustion, and at least as great mechanical injury to the mother, its 
difficulty need not stand in the way of its adoption. 

Treatment when Occlusion of the Os Exists. — When the os is appa- 
rently obliterated, incision is the only resource. Before resorting to it 
the patient should be placed under chloroform and the entire lower seg- 
ment of the uterus carefully explored. Possibly, the aperture may be 
found high up and out of reach of an ordinary examination, or we may 
detect a depression corresponding to its site. A small crucial incision 
may then be made at the site of the os, if this can be ascertained ; if not, 
at the most prominent portion of the cervix. Very generally, the pains 
will then suffice to complete expansion, which may be further aided by 
the fluid dilators. 

Ante-pa, in. i, i Hour-glass Contraction. — Dr. Hosmer 1 has recently 
drawn attention to a hitherto undescribed species of dystocia, which he 
terms " arde-partum hour-glass contraction/' and which he believes to 
depend on constriction of the uterine fibres at the site of the internal os 
uteri. Harris 2 doubts its limitation to the internal os uteri, and terms 
it "tetanoid falciform constriction of the litems." Whatever its site, in 
the cases recorded difficulties of the most formidable kind arose from 
this cause. The pelves were normal and the presentations natural, yet 
out of 7 labors 4 ended fatally, 2 before delivery. [*] The constriction 
seems to have grasped the foetus with such force as to have rendered 
extraction either by the forceps or turning impossible. I have no per- 
sonal experience of this complication, which must fortunately be very 
rare. The introduction of the hand, the patient being deeply ansesthe- 
tized, would probably render diagnosis easy. The treatmenl ruusl 
depend on the force and amount of constriction. II' the constriction 
does not relax under chloroform, chloral, or the Injection of atropine 
into the site of constriction, as recommended by Morton in rigidity of 
the cervix, turning would probably be our best resource. Should tlii- 
fail, the Csesarean section maybe required to effect delivery, as happened 

1 Boston M>l. and. Sun/. Journ., March and May, 1878. 

2 Harris's note t > second American edition. 

[ 3 Of 34 labors, 9 ended fatally ; -J') children were lost. Ed. ] 



356 LABOR. 

in a case recorded by Dr. T. A. Foster of Portland, Maine. Gastro- 
elytrotomy is obviously unsuitable for such cases. 

Bands and Cicatrices in the Vagina. — Extreme rigidity of the vagina, 
or bands and cicatrices in or across its walls, the result of congenital 
malformation, of injuries in former labors, or of antecedent disease, occa- 
sionally obstruct the second stage. There is seldom any really formid- 
able difficulty from this cause, since the obstruction almost always yields 
to the pressure of the presenting part. If there be any considerable 
extent of cicatrices in the vagina, artificial assistance may be. required. 
If we should be aware of their existence during pregnancy, and find 
them to be sufficiently dense and extensive to be likely to interfere with 
delivery, an endeavor may be made to dilate them gradually by hydro- 
static bags or bougies. If they be not detected until labor is in prog- 
ress, we must be guided in our procedure by the pressure to which they 
are subjected. It may then be necessary to divide them with a knife 
and to hasten the passage of the head by the forceps, so as to prevent 
contusion as much as possible. It is obviously impossible to lay down 
any positive rules for such rare contingencies, the treatment suitable for 
which must necessarily vary much with the individual peculiarities of 
the case. 

Extreme rigidity of the perineum is often dependent upon cicatricial 
hardening from injury in previous labors. This may greatly interfere 
with its dilatation ; and if laceration seems inevitable, we may be quite 
justified in attempting to avert it by incision of the margins of the per- 
ineum, on the principle of a clean cut being always preferable to a 
jagged tear. 

Labor Complicated with Tumor. — Occasionally we meet with very 
formidable obstacles from tumors connected with the maternal struc- 
tures. These are most commonly either fibroid or ovarian, although 
others may be met with, such as malignant growths from the pelvic 
bones, exostoses, etc. 

Fibroid Tumors pf the Uterus. — Considering the frequency with which 
women suffer from fibroid tumors of the uterus, it is perhaps somewhat 
remarkable that they do not more often complicate delivery. Probably 
women so affected are not apt to conceive. Occasionally, however, cases 
of this kind cause much anxiety. Of course, the cases are most grave 
in which tumors are so situated as to encroach upon the cavity of the 
pelvis and mechanically obstruct the passage of the child. Even those 
in which this does not occur are by no means free from danger, for inter- 
stitial and subperitoneal fibroids, situated in the upper parts of the ute- 
rus and leaving the pelvic cavity quite unimplieated, may interfere with 
the action of the uterine fibres, prevent subsequent contraction, cause 
profuse post-partum hemorrhage, or even predispose to rupture of the 
uterine tissue. Hence, every case in which the existence of uterine 
fibroids has been ascertained must be anxiously watched. The risk of 
hemorrhage is perhaps the greatest, for if the tumors be at all large, effi- 
cient contraction of the uterus after the birth of the child must be more 
or less interfered with. Fortunately, it is not so common as might 
almost be expected. Out of 5 cases recorded in the Obstetrical Transac- 
tions, 2 of which were in my own practice, no hemorrhage occurred ; nor 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 357 

does it seem to have happened in any of the 26 cases collected by Mag- 
delaine in his thesis on the subject. I recently saw an interesting exam- 
ple of this in a patient whose case was looked forward to with much 
anxiety in consequence of the existence of several enormous fibroid 
masses projecting from the fundus and anterior surface of the body of 
the uterus, and whose labor was, nevertheless, typically normal in every 
way. Should hemorrhage occur after delivery, the injection of styptic 
solutions would probably be peculiarly valuable, since the ordinary 
means of promoting contraction are likely to fail. 

It is when the fibroid growths implicate the lower uterine zone and 
the cervical region that the greatest difficulties are likely to be met with. 
The practice then to be adopted must be regulated to a great extent by 
the nature of each individual case. If it be possible to push the tumor 
above the pelvic brim, out of the way of the presenting part, that, no 
doubt, is the best course to pursue, as not only clearing the passage in 
the most effectual way, but removing the tumor from the bruising to 
which it would otherwise be subjected when pressed between the head 
and the pelvic walls ; which seems to be one of the greatest dangers of 
this complication. This manoeuvre is sometimes possible in what seem 
to be the most unpromising circumstances, ^n interesting example is 
narrated by Spencer Wells, 1 who, called to perform the Csesarean section, 
succeeded, although not without much difficulty, in pushing the obstruct- 
ing mass above the brim, the child subsequently passing with ease. I 
have myself elsewhere recorded two similar cases 2 in which I was en- 
abled to deliver the patient by pushing up the obstructing tumor, in both 
of which the Csesarean section would have been inevitable had the 
attempt at reposition failed. Therefore, before resorting to more seri- 
ous operative procedures a determined effort at pushing the tumor out 
of the way should be made, the patient being deeply chloroformed, and, 
if necessary, upward pressure being made by the closed fist passed into 
the vagina. 

Enucleation or Ablation. — Failing this, the possibility of enucleating 
the tumor, or, if that be not possible, of removing it piecemeal with the 
ecraseur, should be considered. On account of the loo*' attachments of 
these growths, and the facility with which they can be removed in this 
way in the non-pregnant state, the expedient seems certainly well worthy 
of a trial if their site and attachments render it at all feasible. Inter- 
esting examples of the successful performance of this operation are 
recorded by Danyau and Braxton Hicks. Should it he found Imprac- 
ticable, the case must be managed in reference to the amount of obstruc- 
tion, and the forceps, craniotomy, or even the Csesarean Bection, may he 
necessary. 

[The records of Csesarean delivery show a great mortality in cases 
where the dystocia is due to an obstruction produced by fibroid tumors. 
In Dr. Sanger's collection, 8 excluding the Porro operation-, we find 39 
Csesarean sections, with 31 deaths : s ol* the 39 are credited to the I Inited 
States, with 3 recoveries. To this I add 1 more recovery and 2 more 
deaths, giving us 4 saved out of 11, or 12 cases in all, with 9 women 

1 Obst Trans., vol. ix. p. 73. ' Tbid. t vol. xix. p, 101. 

[ 3 Der Kaiserschnitt bei liter usfibr omen, Leipzig, 1882. pp. 12 23. Ed.] 



358 



LABOR. 



saved. An early resort to the knife and suturing the uterine wound 
promise better results in the future. — Ed.] 

Tumors of the Ovaries. — The next most common class of obstructing 
tumors are those of the ovary (Fig. 124) ; and it is apparently not the 
largest of these which are most apt to descend into the pelvic cavity. 
When the tumor is of any considerable size, its bulk is such that it can- 
not be contained in the true pelvis, and it rises into the abdominal cavity 

Fig. 124. 




Labor complicated by Ovarian Tumor. 

with the uterus. Hence, the existence of the tumor that offers the most 
formidable obstacle to the delivery is rarely suspected before labor sets in. 
In order to estimate the results of the various methods of treatment, 
I have tabulated 57 cases. 1 In 13 labor was terminated by the natural 
powers alone, but of these 6 mothers, or nearly one-half, died. In fav- 
orable contrast with these we have the cases in which the size of the 
tumor was diminished by puncture. These are 9 in number, in all of 
which the mother recovered, 5 out of the 6 children being saved. The 
reason of the great mortality in the former cases is apparently the bruis- 
ing to which the tumor, even when small enough to allow the child to be 
squeezed past it, is necessarily subjected. This is extremely apt to set 
up a fatal form of diffuse inflammation, the risk of which was long ago 
pointed out by Ashwell, 2 who draws a comparison between cases in which 
such tumors have been subjected to contusion and cases of strangulated 
hernia ; and the cause of death in both is doubtless very similar. This 
danger is avoided when the tumor is punctured, so as to become flattened 
between the head and the pelvic walls. On this account I think it 
should be laid down as a rule that puncture should be performed in all 
cases of ovarian tumor engaged in front of the presenting part, even 
when it is of so small a size as not to preclude the possibility of delivery 
by the natural powers. 



Obst. Trans., vol. ix. 



2 Guy's Hospital Reports, vol. ii. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 359 

Treatment when Puncture Fails. — In 5 of the 57 cases it was found 
possible to return the tumor above the pelvic brim, and in these also the 
termination was very favorable, all the mothers recovering. Should 
puncture not succeed — and it may fail on account of the gelatinous and 
semi-solid nature of the contents of the cyst — it may be possible to dis- 
pose of the tumor in this way, even when it seems to be firmly wedged 
down in front of the presenting part and to be hopelessly fixed in its 
unfavorable position. 

Failing either of these resources, it may be necessary to resort to 
craniotomy, provided the size of the tumor precludes the possibility of 
delivery by forceps. 

The question of the effect on labor of ovarian tumor which does not 
obstruct the pelvic canal is one of some interest, but there are not a suf- 
ficient number of cases recorded to throw much light on it. I am dis- 
posed to think that labor generally goes on favorably. What delay 
there is depends on the inefficient action of the accessory muscles 
engaged in parturition, on account of the extreme distension of the 
abdomen. 

There are a few other conditions connected with the maternal struc- 
tures which may impede delivery, but which are of comparatively rare 
occurrence. 

Vaginal Cystocele. — Amongst them is vaginal cystocele, consisting of 
a prolapse of the distended bladder in front of the presentation, where 
it forms a tense fluctuating pouch, which has been mistaken for a hydro- 
cephalic head or for the bag of membranes. This complication is only 
likely to arise when the bladder has been allowed to become unduly dis- 
tended from want of attention to the voiding of urine during labor. 
The diagnosis should not offer any difficulty, for the finger will be able 
to pass behind, but not in front of, the swelling, and reach the presenting 
part, while the pain and tenesmus will further put the practitioner on 
his guard. The treatment consists in emptying the bladder ; but there 
may be some difficulty in passing the catheter, in consequence of the 
urethra being dragged out of its natural direction. A long elastic male 
catheter will almost always pass if used with care and gentleness. Should 
it be found impossible to draw off the water — and this is said to have 
sometimes happened — the tense pouch might be punctured without dan- 
ger by the fine needle of an aspirator-trocar and its contents withdrawn. 
When once the viscus is emptied it can easily be pushed above the pre- 
senting part in the intervals between the pains. 

Vesical Calculus. — In some few eases difficulties have arisen from the 
existence of a vesical calculus. Should this be pushed down in Trout, 
of the head, it can readily be understood that the maternal structures 
would run the risk of being seriously bruised and injured. Should we 
make out the existence of a calculus — and if the presence of one !>'• sus- 
pected the diagnosis could easily be made by means of a sound — an 
endeavor should be made to push it above the brim of the pelvis. If 
that be found to be impossible, no resource is left but it- removal, either 
by crushing or by rapid dilatation of the urethra, followed by extrac- 
tion. Should we be aware of the existence of a calculus during preg- 
nancy, its removal should certainly be undertaken before labor sets in. 



360 LABOR. 

Hernial protrusion in Douglas's space may sometimes give rise to 
anxiety, from the pressure and contusion to which it is necessarily sub- 
jected. An endeavor must be made to replace it and to moderate the 
straining efforts of the patient ; and it may even be advisable to apply 
the forceps, so as to relieve the mass from pressure as soon as possible. 
It is, however, of great rarity. Fordyce Barker in an interesting paper 
on the subject 1 records several examples, and states that he has met with 
no instance in which it has led to a fatal result, either to mother or 
child, although it cannot but be considered a serious complication. 

Scybalous masses in the intestines may be so hard and impacted as to 
form an obstruction. The necessity of attending to the state of the rec- 
tum has already been pointed out. Should it be found impossible to 
empty the bowel by large enemata, the mass must be mechanically broken 
down and removed hy the scoop. 

(Edema of the Vulva. — Excessive oedematous infiltration of the vulva 
may sometimes cause obstruction and require diminution in size, which 
can easily be effected by numerous small punctures. 

Hcematic effusions into the cellular tissue of the vulva or vagina form a 
grave complication of labor. Such blood-swellings are most usually met 
with in one or both labia or under the vaginal wall ; in the gravest 
forms the blood may extend into the tissues for a considerable distance, 
as in the case recorded by Cazeaux, where it reached upward as far as 
the umbilicus in front and as far as the attachment of the diaphragm 
behind. 

Conditions Favoring the Accident. — The conditions associated with 
pregnancy, the distension and engorgement to which the vessels are sub- 
jected, the interference with the return of the blood by the pressure of 
the head during labor, and the violent efforts of the patient, afford a 
ready explanation of the reason why a vessel may be predisposed to rup- 
ture and admit of the extravasation of blood. 

The accident is fortunately far from a common one, although a suf- 
ficient number of cases are recorded to make us familiar with its symp- 
toms and risks. The dangers attending such effusions would seem to be 
great, if the statistics given by those who have written on the subject 
are to be trusted. Thus, out of 124 cases collected by various French 
authors, 44 proved fatal. Fordyce Barker points out that since the 
nature and appropriate treatment of the accident have been more thor- 
oughly understood the mortality has been much lessened, for out of 15 
cases reported by Scanzoni, only 1 died, and out of 22 cases he had him- 
self seen, 2 died ; and all these 3 deaths were from puerperal fever, and 
not the direct result of the accident. 2 

Situation of the Blood-Effusion. — The blood may be effused into any 
part of the pelvic cellular tissue or into the labia. The accident most 
often happens during labor when the head is low down in the pelvis, not 
unfrequently just as it is about to escape from the vulva. Hence the 
extravasation is more often met with low down in the vagina, and more 
frequently in one of the labia than in any other situation. I have met 
with a case in which I had every reason to believe that an extravasation 
of blood had occurred within the tissues immediately surrounding the 

1 Amer. Journ. of Obst., vol. ix. 2 The Puerperal Diseases, p. 60. 



OBSTRUCTION FROM CONDITION OF SOFT PARTS. 361 

cervix. It is natural to suppose that a varicose condition of the veins 
about the vulva would predispose to the accident-" but in most of the 
recorded examples this is not stated to have been the case. Still, if vari- 
cose veins exist to any marked degree some anxiety on this point cannot 
but be felt. 

Time of Occurrence. — The thrombus occasionally, though rarely, 
forms before delivery. Most commonly it first forms toward the end 
of labor or after the birth of the child. In the latter case it is probable 
that the laceration in the vessels occurred before the birth of the child, 
and that the pressure of the presenting part prevented the escape of any 
quantity of blood at the time of laceration. 

Symptoms. — The symptoms are not by any means characteristic. Pain 
of a tearing character, occasionally very intense, and extending to the 
back and down the thighs, is very generally associated with the forma- 
tion of the thrombus. If a careful physical examination be made, the 
nature of the case can readily be detected. When the blood escapes into 
the labium, a firm, hard swelling is felt, which has even been mistaken 
for the foetal head. If the effusion implicate the internal parts only, 
the diagnosis may not at first be so evident. But even then a little care 
should prevent any mistake, for the swelling may be felt in the vagina, 
and may even form an obstacle to the passage of the child. Cazeaux 
mentions cases in which it was so extensive as to compress the rectum 
and urethra, and even to prevent the exit of the lochia. In some cases 
the distension of the tissues is so great that they lacerate, and then hem- 
orrhage, sometimes so profuse as directly to imperil the life of the patient, 
may occur. The bursting of the skin may take place some time subse- 
quent to the formation of the thrombus. Constitutional symptoms will 
be in proportion to the amount of blood lost, either by extravasation or 
externally, after the rupture of the superficial tissues. Occasionally they 
are considerable, and are the same as those of hemorrhage from any 
cause. 

Terminations. — The terminations of thrombus are either spontaneous 
absorption, which may occur if the amount of blood extravasated be 
small ; or the tumor may burst, and then there is external hemorrhage ; 
or it may suppurate, the contained coagula being discharged from the 
cavity of the cyst; or, finally, sloughing of the superficial tissues lias 
occurred. 

Treatment. — The treatment must naturally vary with the size of the 
thrombus and the time at which it forms. If it be met with during 
labor, unless it be extremely small it will be very apt to form an obstruc- 
tion to the passage of the child. Under such circumstances it is clearly 
advisable to terminate the labor as soon as possible, so as to remove the 
obstacle to the circulation in the vessels. For this purpose tin- forceps 
should be applied as soon as the head can be easily reached. II' the 
tumor itself obstruct the passage of the head or if it be of anv consider- 
able size, it will be necessary to incise it freely at its most prominent 
point and turn out the coagula, controlling the hemorrhage at once by 
filling the cavity with cotton wadding saturated in a solution of per- 
chloride of iron, while at the same time digital compression with the 
tips of the fingers is kept up. By this means pressure i> applied directly 



362 LABOR. 

to the bleeding point, and the hemorrhage can be controlled without 
difficulty. This is all the more necessary if spontaneous rupture have 
taken place, for then the loss of blood is often profuse, and it is of the 
utmost importance to reach the site of the hemorrhage as nearly as 
possible. 

If the thrombus be not so large as to obstruct delivery, or if it be not 
detected until after the birth of the child, the question arises whether 
the case should not be left alone, in the hope that absorption may occur, 
as in most cases of pelvic hsematocele. This expectant treatment is 
advised by Cazeaux, and it seems to be the most rational plan we can 
adopt. True, it may take a longer time for the patient to convalesce 
completely than if the coagula were removed at once and the hemor- 
rhage restrained by pressure on the bleeding point ; but this disadvan- 
tage is more than counterbalanced by the absence of risk from hemor- 
rhage, and of septicaemia from the suppuration that must necessarily 
follow. Softening and suppuration may in many cases occur in a few 
days, necessitating operation, but the vessels will then be probably 
occluded and the risk of hemorrhage much lessened. Dr. Fordvce 
Barker, how r ever, holds the opposite opinion, and thinks that the proper 
plan is to open the thrombus early, controlling the hemorrhage in the 
manner already indicated, unless the thrombus is situated high in the 
vaginal canal. 

Risk of Subsequent Septiecemia. — Whenever the cavity of a thrombus 
has been opened, either by incision or by spontaneous softening at some 
time subsequent to its formation, it must not be forgotten that there is 
considerable risk of septic absorption. To avoid this, care must be 
taken to use antiseptic dressings freely, such as the glycerin of carbolic 
acid, applied directly to the part, and frequent vaginal injections of 
diluted Condy's fluid. Barker lays special stress on the importance 
of not removing prematurely the coagula formed by the styptic applica- 
tions for fear of secondary hemorrhage, but of allowing them to come 
away spontaneously. 

\_Polypus. — Large uterine polypi may act as serious obstacles to 
delivery. When sufficiently long in pedicle, a polypus may be extruded 
before the head of the foetus. The tumor may also be detached in its 
expulsion, or may be removed by an ecraseur if recognized in time : it 
may also be pushed up out of the way and secured by bringing down 
the child. I once replaced a large polypus that was extruded before the 
head, and the woman carried it two years longer ; by which time, being 
much wasted by the discharge, she made up her mind to have it 
removed. — Ed.] 



DYSTOCIA FROM FCETUS. 



363 



CHAPTER XI. 

DIFFICULT LABOK DEPENDING OX SOME UNUSUAL CONDITION 

OF THE FCETUS. 



Fig. 125. 



Plural Births. — The subject of multiple pregnancy in general having 
already been fully considered, we have now only to discuss its practical 
bearing as regards labor. Fortunately, the existence of twins rarely 
gives rise to any serious difficulty. In the large proportion of cases the 
presence of a second foetus is not suspected until the birth of the first, 
when the nature of the case is at once apparent from the fact of the 
uterus remaining as large, or nearly as large, as it was before. 

There may possibly be some delay in the birth of the first child, 
inasmuch as the extreme distension of the uterus may interfere with its 
thoroughly efficient action, while, in addition, the uterine pressure is not 
directly conveyed to the ovum as in sin- 
gle births, but indirectly through the 
amniotic sac of the second child (Fig. 
125). Such delay is especially apt to 
arise when the first child presents by the 
breech, for even if the body be expelled 
spontaneously, difficulty is likely to occur 
with the head, since the uterus does not 
contract upon it, as is ordinarily the 
case. Hence the intervention of the 
accoucheur to save the life of the child 
by the extraction of the head will be 
almost a matter of necessity. 

In the majority of cases, after the 
birth of the first child there is a tem- 
porary lull in the pains, which soon 
recommence, generally in from ten to 
twenty minutes, and the second child is 
rapidly expelled, for on account of the 
full dilatation of the soft parts there is 
no obstacle to its delivery. Sometimes 
there is a considerable interval before the 
pains recur, and instances arc recorded in which even several i\ny- have 
elapsed between the births of the two children. 

Treatment. — In most cases the management of twins does not differ 
from that of ordinary labor. Ajb sood ;i- we are certain of the exist- 
ence of a second foetus, we should inform the bystanders, bu1 not 
necessarily the' mother, to whom the news might prove an unpleasant 
and even dangerous shock. Then, having taken care to tie the cord of 
the first child for fear of vascular communication between the placentae, 
our duty is to wait for a recurrence of the pains. If these come on 




T\vin Pregnancy, Breech and 
Presenting. 



rild 



364 LABOR. 

rapidly and the presentation of the second foetus be normal, its birth is 
managed in the usual way. 

Management when there is Delay after the Birth of the First Child. — 
If there be any unusual delay, we have to consider the proper course to 
pursue, and on this the opinions of authorities differ greatly. Some 
advise a delay of several hours, and even more, if pains do not recur 
spontaneously ; while others — Murphy, for example — recommend that 
the second child should be delivered at once. Either extreme of prac- 
tice is probably wrong, and the safest and best course is doubtless the 
medium one. The second point to bear in mind is, that in multiple 
pregnancy, on account of the extreme distension of the uterus, there is a 
tendency to inertia, and consequently to post-partum hemorrhage, and 
that, therefore, it is better that the birth of the second child should be 
delayed, even for a considerable time, rather than the patient should run 
the risk attending an empty and uncontracted uterus. If, however, 
uterine action be present, there is an obvious advantage in the delivery 
of the second child before the dilatation of the passages passes off. 

Endeavors should be made to Excite Uterine Action. — The best plan 
would seem to be if, after waiting a quarter of an hour, labor-pains do 
not occur, to try and induce them by uterine friction and pressure and 
by the administration of a dose of ergot, to which, as there can be no 
obstacle to the rapid birth of the second child, there can be now no 
objection. The membranes of the second child should always be rup- 
tured at once if easily within reach, as one of the speediest means of 
inducing contraction. If no progress be made, and speedy delivery be 
indicated — a necessity which may arise either from the exhausted state 
of the patient, the presence of hemorrhage, extremely feeble pulsations 
of the fcetal heart (showing that the life of the second child is endan- 
gered), or malpresentations of the second foetus — turning is probably the 
readiest and safest expedient. Under such circumstances the operation 
is performed with great ease, since the passages are amply dilated. 
After bringing down the feet, the birth of the body should be slowly 
effected, with the view of ensuring as complete subsequent contraction 
as possible. If the head has descended in the pelvis, of course turning 
is impossible and the forceps must be applied. 

Difficulties arising from Locked Tivins. — Occasionally, very serious 
difficulties arise from parts of both foetuses presenting simultaneously, 
and thus impeding the entrance of either child into the pelvis, or getting 
locked together, so as to render delivery impossible without artificial aid. 
Such difficulties are not apt to arise in the more ordinary cases, in which 
each child has its own bag of membranes, since then the foetuses are kept 
entirely separate, but in those in which the twins are contained in a 
common amniotic cavity or in which both sacs have burst simultaneously. 
They are very puzzling to the obstetrician, and it may be far from easy 
to discover the cause of the obstruction. Nor is it possible to lay down 
any positive rules for their management, which must be governed to a 
considerable extent by the circumstances of each individual case. 

Both Heads Presenting Simultaneously. — Sometimes both heads present 
simultaneously at the brim, and then neither can enter unless they be 
unusually small or the pelvis very capacious, when both may descend ; 



DYSTOCIA FROM FCETUS. 



365 



or, rather, the first head may descend low into the pelvic cavity, and then 
the second head enters the brim and gets jammed against the thorax of 
the first child (Fig. 126). Eeimann 1 relates a curious example of this, 
in which he delivered the head first with the forceps, but found the body 
would not follow, and on examination a second head was found in the 
pelvis. He then applied the forceps to the second head ; the body of 
the first child was then born, and afterward that of the second. Such a 



Fig 




Shows Head-Locking, both Children Presenting Head First. (After Barnes.) 

mechanism must clearly have been impossible unless the pelvis had beeD 
extremely large. 

Whenever both heads are felt at the brim, it will generally be found 
possible to get one out of the way by appropriate manipulation, one hand 
being passed into the vagina, the other aiding its action from without. 
Then the forceps may be applied to the other head, so as to engage it at 
once in the pelvic cavity. If both have actually passed into the pelvis, 
as in the case just alluded to, the difficulty will be much greater. It 
will generally be easier to push up the second head, while the lower is 
drawn out by the forceps, than to deliver the second, Leaving the first 
in situ. 

Foot or Hand with Head. — In other eases a foot or hand may descend 
along with the head, and even the four feet may present simultaneously. 
The rule in the former case is to push the part descending with the head 
out of the way, and in the latter to disengage one child ;i- soon :i- pos- 
sible. Great care is necessary, or we might possibly bring down the limbs 
of separate children. 

Two Heads interlocking in Head and Breech Presentations. — The 
most common kind of difficulty is when the first child presents by the 

1 Arch. f. Gyncek., 1871. 



366 



LABOR. 



breech and is delivered as far as the head, which is then found to be 
locked with the head of the second child, which has descended into the 
pelvic cavity (Fig. 127). 

Here it is clear that the obstruction must be very great, and, unless 
the children are extremely small, insuperable. The first endeavor should 
be to disentangle the head : this is sometimes feasible if the second be 
not deeply engaged in the pelvis, and the hand be passed up so as to 
push it out of the way. This will but rarely succeed : then it may be 
possible to apply the forceps to the second head and drag it past the body 

Fio. 127. 




Shows Head-locking, First Child coming Feet First ; Impaction of Heads from Wedging in 

Brim. (After Barnes.) 

d. Apex of wedge. E, c. Base of wedge which cannot enter brim, a, b. Line of decapitation to 

decompose wedge and enable head of second child to pass. 

of the first child ; and this is the method recommended by Reimann, 
who has written an excellent paper on the subject, 1 Generally, the sacri- 
fice of one of the children is essential, and as the body of the first child 
must have been born for some time, it is probable that the pressure to 

1 American Journal of Obstetrics, January, 1877. 



DYSTOCIA FROM FOETUS. 367 

which it has been subjected will have already imperilled, if it has not 
destroyed, its life, and therefore the plan usually recommended is to 
decapitate. This can easily be done with scissors or a wire ecraseur, 
after which the second child is expelled without difficulty, leaving the 
head of the first in utero to be subsequently dealt with. 

Another mode of managing these cases is to perforate the upper head 
and draw it past the lower with the omphalotribe or craniotomy-forceps. 
This plan has the disadvantage of probably sacrificing both children, 
since the other child can hardly survive the pressure and delay, whereas 
the former plan gives the second child a fair chance of being born alive. 

Double Monsters. — In connection with the subject of twin labor we 
may consider those rare cases in Avhich the bodies of the foetuses are par- 
tially fused together. The mechanism and management of delivery in 
cases of double monstrosity have attracted comparatively little attention, 
no doubt because authors have considered them matters of curiosity 
merely, rather than of practical importance. 

The frequent occurrence of such monstrosities in our museums, and 
the numerous cases scattered through our periodical literature, are suf- 
ficient to show that they are not so very rare as we might be inclined to 
imagine ; and, as they are likely to give rise to formidable difficulties in 
delivery, it cannot be unimportant to have a clear idea of the usual 
course taken by nature in effecting such births, with a view of enabling 
us to assist in the most satisfactory manner should a similar case come 
under our observation. 

Unfortunately, the authors who have placed on record the birth of 
double monsters have generally occupied themselves more with a descrip- 
tion of the structural peculiarities of the foetuses than with the mechan- 
ism of their delivery ; so that, although the cases to be met with in 
medical literature are very numerous, comparatively few of them are of 
real value from an obstetric point of view. Still, I have been able to 
collect the details of a considerable number 1 in which the history of the 
labor is more or less accurately described ; and doubtless a more exten- 
sive research would increase the list. 

For obstetric purposes we may confine our attention to four principal 
varieties of double monstrosity which are met with far more frequently 
than any others. These are : 

A. Tw t o nearly separate bodies united in front, to a varying extent, 
by thorax or abdomen. 

B. Two nearly separate bodies united back to back by the sacrum and 
lower part of the spinal column. 

C. Dicephalous monsters, the bodies being single below, but the heads 
separate. 

D. The bodies separate below, but the heads partially united. 

This classification by no means includes all the varieties of monsters 
that we may meet with. It does, however, include all thai are likely to 
give rise to much difficulty in delivery ; and all the cases I have col- 
lected may be placed under one of these division-. 

The first point that strike- us in looking over the history of these 
deliveries is the frequency with which they have been terminated by the 

1 Obst. Trans., vol. viii. 



368 LABOR. 

natural powers alone, without any assistance on the part of the accou- 
cheur. Thus, out of the 31 cases, no less than 20 were delivered nat- 
urally, and apparently without much trouble. Nothing can better 
show the wonderful resources of nature in overcoming difficulties of a 
very formidable kind. 

It is pretty generally assumed by authors that the children are neces- 
sarily premature, and therefore of small size, and that delivery before 
the full term is rather the rule than the exception. Dug6s states that 
the children are often dead, and that putrefaction has taken place, which 
facilitates their expulsion. Both these assumptions seem to me to have 
been made without sufficient authority, and not to be borne out by the 
recorded facts. In only 1 of the 31 cases is it mentioned that the chil- 
dren were premature ; nor is there any sufficient reason that I can see 
why labor should commence before the full term of gestation. 

Class A. — By far the greatest number are included in the first class — 
that in which the bodies are nearly separate, but united by some part of 
the thorax or abdomen. This is the division which includes the cele- 
brated Siamese Twins, an account of whose birth, I may observe, I 
have not been able to discover. 1 Out of the 31 cases, 19 come under 
this heading. The details of the labor are briefly as follows : 1 died 
undelivered ; 8 were terminated by the natural powers, in 3 of which 
the feet, and in 3 the head, presented ; in 2 the presentation is doubtful ; 
6 were delivered by turning or by traction on the lower extremities ; 4 
were delivered instrumentally. 

Footling Presentation is the most Favorable. — The details of the cases 
in which the feet presented or in which turning was performed clearly 
show that footling presentation was by far the most favorable, and it is 
fortunate the feet often present naturally. The inference of course is, 
that version should be resorted to whenever any other presentation is 
met with in cases of double monstrosity of this type; but, unfortu- 
nately, this rule could rarely be carried into execution, since we possess 
no means of diagnosing the junction of the foetuses at a sufficiently early 
stage of labor to admit of turning being performed. It is only under 
exceptionally favorable circumstances that this can be done ; as, for 
example, in a case recorded by Molas, 2 in which both heads presented, 
but neither would enter the brim of the pelvis. 

The Chief Difficulty is in the Delivery of the Heads. — The great diffi- 
culty must, of course, be in the delivery of the heads, for in all the record- 
ed cases, with one exception, the bodies have passed through the pelvis 
parallel to each other with comparative ease until the necks have ap- 
peared, and then, as a rule, they could be brought no farther. It is 
clear that the remainder of the foetuses could no longer pass simultane- 

1 The mother of these twins was a Chinese half-breed, short, and with a broad pelvis, 
and had borne several children previously. She stated on several occasions, in conver- 
sation with parties in Siam, that the twins were born reversed, the feet of one being 
followed by the head of the other, and that they were very small and feeble at birth 
and for several months afterward. The twins confirmed this statement by affirming 
that they could, when little boys at play on the ground, turn themselves end for end 
upon the ensiform attachment up to the age of ten or twelve, the attachment being 
then soft and pliable (Harris's note to second American edition). 

2 Mem. de /' Academic vol. i. 



DYSTOCIA FROM FOETUS. 369 

ously, and were direct traction continued the heads would be inextrica- 
bly fixed above the brim. In accordance with the direction of the pelvic 
axes the posterior head must first engage in the inlet ; and in order to 
effect this it will be necessary to carry the bodies of the children well 
over the abdomen of the mother. This seems to be a point of primary 
importance. It would also be advisable to see that the bodies are made 
to pass through the pelvis with their backs in the oblique diameter. By 
this means more space is gained than if the backs were placed antero- 
posteriorly, while at the same time there is less chance of the heads 
hitching against the promontory of the sacrum and symphysis pubis, 
which otherwise would be very apt to occur. 

Mode of Delivery when the Head Presents. — When the head presents, 
and the labor is terminated by the natural powers, delivery seems to be 
accomplished in one of two ways. 

In the first and more common the head and shoulders of one child 
are born, its breech and legs being subsequently pushed through the 
pelvis by a process similar to that of spontaneous evolution ; and 
afterward the second child probably passes footling without much 
difficulty. 

Barkow relates a case in which both heads were delivered by the 
forceps, the bodies subsequently passing simultaneously. Two similar 
instances are recorded in the third and sixth volumes of the Obstetrical 
Transactions. When delivery takes place in this manner the head of 
the second child must fit into the cavity formed by the neck of the first, 
and the pelvis must necessarily be sufficiently roomy to admit of the 
expulsion of the head of the second child, while its cavity, is diminished 
in size by the presence of the neck and shoulders of the first. Kit he;' 
of these processes must obviously require exceptionally favorable con- 
ditions as regards the size of the child and the pelvis, and the difficulty 
in the way of delivery must be much greater than when the lower 
extremities present. Therefore, I think the rule should be laid down 
that when the nature of the case is made out (and for the purpose of 
accurate diagnosis a complete examination under anaesthesia should be 
practised) turning should be performed and the feet brought down. 

Mutilation of the Foetuses. — In the event of its being found impossi- 
ble to effect delivery after a considerable portion of the bodies is born, 
no resource remains but the mutilation of the body of one child so a- to 
admit of the passage of the other. This was found necessary in one 
ease in which the children presented by the feet and were born a- far as 
the thorax, but could get no farther. The body of the anterior child 
was removed by a circular incision as far as it had been expelled, which 
allowed the remaining portion, consisting of the head and shoulders, to 
re-enter the uterus: after this the posterior child was easily extracted, 
and the mutilated foetus followed without difficulty. 

Class B. — In Class B, in which the children are united back t<> back, 
3 cases are recorded, all of which were delivered by the natural powers. 
One of these is the case of Judith and E6l&ne, the celebrated Hungarian 

twins, who lived to the age of twenty-one. Ilelene was bom a- far as 

the umbilicus, and after the lapse of three hours her breech and legs de- 
scended. Judith was expelled immediately afterward, her feel descend- 

24 



370 LAB OB. 

ing first. [ x ] Exactly the same process occurred in a case described by 
M. Norman, the children being also born alive, and dying on the ninth 
day. 

Labor is Easier than in Class A. — It is probable that labor is easier 
in this class of double monsters than in the former, because the children 
are so joined that there is no necessity for the bodies to be parallel to 
each other during birth when the head presents, and after the birth of 
the head and shoulders of the first child its breech and lower extremities 
are evidently pushed down and expelled by a process of spontaneous 
evolution. If the feet originally presented, the mechanism of delivery 
and the rules to be followed would be the same as in Class A ; but the 
difficulty would probably be greater, since the juncture is not so flexible, 
and a more complete parallelism of the bodies would be necessary during 
extraction. 

Class C. — In Class C, that of the dicephalous monster, I have found 
the description of the birth of 8 cases, 3 of which were terminated by 
the natural powers. In 2 of these the process of evolution was the 
main agent in delivery, one head being born and becoming fixed un- 
der the arch of the pubes, the body being subsequently pushed past 
it, and the second head following without difficulty. This j^rocess fail- 
ing, the proper course is to decapitate the first-born head, and then 
bring down the feet of the child, when delivery can be accomplished 
with ease. This was the course adopted in 2 out of the 8 cases ; and it 
may be done with the less hesitation since, from their structural pecu- 
liarities, it is exceedingly improbable that monsters of this kind should 
survive. In jthe third case, terminated naturally, the heads were said 
to have been born simultaneously, but it seems probable that the one 
head lay in the hollow formed by the neck of the other, and so rapidly 
followed it. If the feet presented, the case may be managed in the same 
manner as in Class A. 

Class D. — Monstrosities of Class D, in which the heads are united, 
the bodies being distinct, appear to be the most uncommon of all, and I 
can find the description of delivery in only 2 cases. One of these gave 
rise to great difficulty ; the labor in the other was easy. "We should 
scarcely anticipate much difficulty in the birth of monsters of this type, 
for if the head presented and would not pass, we should naturally per- 
form craniotomy ; and if the bodies came first, the delivery of the mon- 
strous head could readily be accomplished by perforation. 

Result to the Mothers. — The result to the mothers in all these cases 
seems to have been very favorable. There is only one in which the 
death of the mother is recorded ; and although in many the result is 
not mentioned, we may fairly assume that recovery took place. 

Among difficulties in labor, some of the most important are due to 
morbid conditions of the foetus itself. 

Infra-uterine Hydrocephalus. — Of these, the most common as well as 

\} The celebrated colored Carolina twins, born July 11, 1851. and still living, were 
brought into the world by the same method, but the mother, having a large pelvic, 
"had a brief and easy" delivery. The Larger of the two girls also eanie first, as in the 
Tzoni case of 1701. These twins are now 1885 twelve years older than the Hunga- 
rian sisters were at death, being 33 years of age. — Ed.] 



DYSTOCIA FROM FOETUS. 



371 



the most serious is caused by intra-uterine hydrocephalus (giving rise to 
a, collection of watery fluid within the cranium), by which thedimen- 
sious of the child's head are enormously increased and the due relations 
between it and the pelvic cavity entirely destroyed (Fig. 128). 

Its Banger both as Regards the Mother and Child. — Fortunately, this 
disease is of comparatively rare occurrence, for it is one of great gravity 
both as regards the mother and child. As regards the mother, the seri- 
ous character of the complication is proved by the statistics of Dr. 
Keiller of Edinburgh, who found that out of 74 cases no less than 16 
were accompanied by rupture of the uterus. The reason of the danger 
to which the mother is subjected is obvious. In some few cases, indeed, 
the head is so compressible that, provided the amount of contained fluid 



Fig. 128. 




Labor Impeded by Hydrocephalus 



be small, it may be sufficiently diminished in size by the moulding to 
which it is subjected to admit of its being squeezed through the pelvis. 
In the majority of cases, however, the size of the head is t<><» greal for 
tlii- to occur. The uterus therefore exhausts itself, and may even rup- 
ture, in the vain endeavor to overcome tin 1 obstacle ; while the large and 
distended head presses firmly oh the cervix or on the pelvic tissues if the 
OS be dilated, and all the evil effects of prolonged compression are apt to 

follow. 

Its Diagnosis is not always Easy. — The diagnosis of intra-uterine 
hydrocephalus is by no means so easy as the description in obstetric 
works would lead as to believe. It is true thai the head is much larger 
and more rounded in its contour than the healthy foetal cranium, and 
also that the sutures and fbntanelles are more wide, and admit occasion- 
ally of fluctuation being perceived through them. Still, it i- t<» be 
remembered that the head is always arrested above the brim, where n is 
consequently high up and difficult to reach, and where these peculiarities 



372 LABOR. 

are made out with much difficulty. As a matter of fact, the true nature 
of the case is comparatively rarely discovered before delivery ; thus, 
Chaussier 1 found that in more than one-half of the cases he collected 
an erroneous diagnosis had been made. 

Method of Diagnosis. — Whenever we meet with a case in which either 
the history of previous labor or a careful examination convinces us that 
there is no obstacle due to pelvic deformity, in which the pains are 
strong and forcing, but in which the head persistently refuses to engage 
in the brim, we may fairly surmise the existence of hydrocephalus. 
Nothing, however, short of a careful examination under anaesthesia, the 
whole hand being passed into the vagina so as to explore the presenting 
part thoroughly, will enable us to be quite sure of the existence of this 
complication. Under these circumstances such a complete examination 
is not only justified, but imperative ; and when it has been made the dif- 
ficulties of diagnosis are lessened, for then we may readily make out the 
large round mass, softer and more compressible than the healthy head, 
the widely-separated sutures, and the fluctuating fontanelles. 

Pelvic Presentations are Frequently met with. — In a considerable pro- 
portion of cases — as many, it is said, as 1 out of 5 — the foetus presents 
by the breech. The diagnosis is then still more difficult ; for the labor 
progresses easily until the shoulders are born, when the head is com- 
pletely arrested, and refuses to pass with any amount of traction that is 
brought to bear on it. Even the most careful examination may not 
enable us to make out the cause of the delay, for the finger will impinge 
on the comparatively firm base of the skull, and may be unable to reach 
the distended portion of the cranium. At this time abdominal palpa- 
tion might throw some light on the case, for, the uterus being tightly 
contracted round the head, we might be able to make out its unusual 
dimensions. The wasted and shrivelled appearance of the child's body, 
which so often accompanies hydrocephalus, would also arouse suspicion as 
to the cause of delay. On the whole, such cases may be fairly assumed 
to be less dangerous to the mother than when the head presents ; for in 
the latter the soft parts are apt to be subjected to prolonged pressure and 
contusion, while in the former delay does not commence till after the 
shoulders are born, and then the character of the obstacle would be 
sooner discovered and appropriate means earlier taken to overcome it. 

Treatment — The treatment is simple, and consists in tapping the 
head, so as to allow the cranial bones to collapse. There is the less 
objection to this course since the disease almost necessarily precludes the 
hope of the child's surviving. The aspirator would draw off the fluid 
effectually, and would at least give the child a chance of life ; and under 
certain circumstances the birth of a child who lives for a short time only 
may be of extreme legal importance. More generally the perforator 
will be used, and as soon as it has penetrated a gush of fluid will at once 
verify the diagnosis. Schroeder recommends that after perforation 
turning should be performed, on account of the difficulty with which the 
flaccid head is propelled through the pelvis. This seems a very unne- 
cessary complication of an already sufficiently troublesome case. As a 
rule, when once the fluid has been evacuated, the pains being strong, as 

1 Gazette merficale, 1 864. 



DYSTOCIA FROM FCETUS. 373 

they generally are, no delay need be apprehended. Should the head not 
come down, the cephalotribe may be applied, which takes a firmer grasp 
than the forceps, and enables the head to be crushed to a very small size 
and readily extracted. 

Treatment when the Breech Presents. — When the breech presents, the 
head must be perforated through the occipital bone ; and generally this 
may be accomplished behind the ear without much difficulty. In a case 
of Tanner's 1 the vertebral column was divided by a bistoury, and an 
elastic male catheter introduced into the vertebral canal, through which 
the intra-cranial fluid escaped, the labor being terminated spontaneous! v. 
In any case in which it is found difficult to reach the skull with the per- 
forator this procedure should certainly be tried. 

Other forms of dropsical effusion may give rise to some difficulty, but 
by no means so serious. In a few rare cases the thorax has been so dis- 
tended with fluid as to obstruct the passage of the child. Ascites is 
somewhat more common, and occasionally the child's bladder is so dis- 
tended with urine as to prevent the birth of the body. The existence 
of any of these conditions is easily ascertained ; for the head or breech, 
whichever happens to present, is delivered without difficulty, and then 
the rest of the body is arrested. This will naturally cause the practi- : 
tioner to make a careful exploration, when the cause of the delay will be 
detected. 

The treatment consists in the evacuation of the fluid by puncture. In 
the case of ascites this should always be done, if possible, by a fine trocar 
or aspirator, so as not to injure the child. This is all the more import- 
ant since it is impossible to distinguish a distended bladder from 
ascites, and an opening of any size into that viscus might prove fatal, 
whereas aspiration would do little or no harm, and would prove quite 
as efficacious. 

Fa?tal Tumors Obstructing Delivery. — Certain foetal tumors may occa- 
sion dystocia, such as malignant growths or tumors of the kidney, liver, 
or spleen. Cases of this kind are recorded in most obstetric works. 
Hydro-encephalocele or hydro-rachitis, depending on defective forma- 
tion of the cranial or spinal bones, with the formation of a large pro- 
truding bag of fluid, is not very rare. The diagnosis of all such cases 
is somewhat obscure, nor is it possible to lay down any definite rules for 
their management, which must vary according to the particular exigen- 
cies. I ne tumors are rarely of sufficient size to prove formidable obsta- 
cles to delivery, and many of them are very compressible. This is 
specially the case; with the spina bifida and similar cystic growths. 
Puncture, and in the more solid growths of the abdomen or thorax 
evisceration, may be required. 

Other (hnfjcnital Def(yrmitie8. — Other deformities, such as the anen- 
cephalous fetus, or defective development of the thorax or abdominal 
parietes with protrusion of the viscera, are not likely to cause difficulty, 
but they may much embarrass the diagnosis by the strange and unusual 
presentation that is felt. If in any case of doubt a full and careful 
examination be undertaken, introducing the whole hand if necessary, no 
serious mistake is likely to he made. 

1 Ifergott, Maladies Fcetalen qui peuventfaire nhsiar/c <) P accouchement, Paris, I i 



374 LABOR. 

Dystocia from Excessive Development of the Foetus. — In addition to 
dystocia from morbid conditions of the foetus, difficulties may arise from 
its undue development, and especially from excessive size and advanced 
ossification of the skull. This last is especially likely to cause delay. 
Even the slight difference in size between the male and female head was 
found by Simpson to have an appreciable effect in increasing the diffi- 
culty of labor when the statistics of a large number of cases were taken 
into account ; for he proved beyond doubt that the difficulties and cas- 
ualties of labor occurred in decidedly larger proportion in male than in 
female births. Other circumstances besides sex have an important effect 
on the size of the child. Thus, Duncan and Hecker have shown that 
it increases in proportion to the age of the mother and the frequency of 
the labors ; while the size of the parents has no doubt also an important 
bearing on the subject. 

Although these influences modify the results of labor en masse, they 
have little or no practical bearing on any particular case, since it is im- 
possible to estimate either the size of the head or the degree of its ossi- 
fication until labor is advanced. 

Treatment. — When labor is retarded by undue ossification or large size 
of the head, the cause must be treated on the same general principles 
which guide us when the want of proportion is caused by pelvic contrac- 
tion. Hence, if delay arise which the natural powers are insufficient to 
overcome, it will seldom happen that the disproportion is too great for 
the forceps to overcome. If we fail to deliver by it, no resource is left 
but perforation. 

Large Size of the Body rarely causes Delay. — Large size of the body 
of the child is still more rarely a cause of difficulty, for if the head be 
born the compressible trunk will almost always follow. Still, a few 
authentic cases are on record in which it was found impossible to extract 
the foetus on account of the unusual bulk of its shoulders and thorax. 
Should the body remain firmly impacted after the birth of the head, it 
is easy to assist its delivery by traction on the axillae, by gently aiding 
the rotation of the shoulders into the antero-posterior diameter of the 
pelvic cavity, and, if necessary, by extracting the arms, so as to lessen 
the bulk of the part of the body contained in the pelvis. Hicks relates 
a case in which evisceration Avas required for no other apparent reason 
than the enormous size of the body. The necessity for any such extreme 
measure must of course be of the greatest possible rarity, and it is quite 
exceptional for difficulty from this source to be beyond the powers of 
nature to overcome. 



DEFORMITIES OF THE PELVIS. 375 



CHAPTER XII. 

DEFOKMITIES OF THE PELVIS. 

Importance of the Subject. — Deformities of the pelvis form one of the 
most important subjects of obstetric study, for from them arise sonic of 
the gravest difficulties and dangers connected with parturition. A know- 
ledge, therefore, of their causes and effects, and of the best mode of detect- 
ing them, either during or before labor, is of paramount necessity ; but 
the subject is far from easy, and it has been rendered more difficult than 
it need be from over-anxiety on the part of obstetricians to force all 
varieties of pelvic deformities within the limits of their favorite classi- 
fication. 

Difficulties of Classification. — Many attempts in this direction have 
been made, some of which are based on the causes on which the deformi- 
ties depend, others on the particular kind of deformity produced. The 
changes of form, however, are so various and irregular, and similar or 
apparently similar causes so constantly produce different effects, that all 
such endeavors have been more or less unsuccessful. For example, we 
find that rickets (of all causes of pelvic deformity the most important) 
generally produces a narrowing of the conjugate diameter of the brim, 
while the analogous disease, osteo-malacia, occurring in adult life, gener- 
ally produces contraction of the transverse diameter, with approximation 
of the pubic bones and relative or actual elongation of the conjugate 
diameter. We might, therefore, be tempted to classify the results of 
these two diseases under separate heads, did we not find that when rickets 
affects children avIio are running about and subject to mechanical influ- 
ences similar to those acting upon patients suffering from osteo-malacia, 
a form of pelvis is produced hardly distinguishable from that met with 
in the latter disease, which by some authors is described as the pseiido- 
osteo-malacic. 

Most Simple Classification. — On the whole, therefore, the most simple 
a- well as the most scientific classification is that which takes as its basis 
the particular seat and nature of the deformity. Let us firs! glance at 
the most common causes. 

Causes of Pelvic Deformity. — The key to the particular shape assumed 
by a deformed pelvis will be found in a knowledge of the circumstances 
which lead to its regular development and normal shape in a state of 
health. The changes produced may, almost invariably, he traced to the 
action of the same causes which produce a normal pelvis, bul which, 
under certain diseased conditions of the bone- or articulations, induce a 
more or less serious alteration in form. These have been already 
described in discussing the normal anatomy of the pelvis; and it will 
be remembered that they are chiefly the weight of the body transmitted 
to the iliac bones through the sacro-iliac joints, and counter-pressure on 
these acting through .the acetabula. Sometimes they ad in excess on 



376 LABOR. 

bones which are healthy, but possibly smaller than usual, and the result 
may be the formation of certain abnormalities in the size of the various 
pelvic diameters. At other times they operate on bones which are 
softened and altered in texture by disease, and which therefore yield to 
the pressure far more than healthy bones. 

The two diseases which chiefly operate in causing deformity are rickets 
and osteo-malacia. Into the essential nature and symptomatology of 
these complaints it would be out of place to enter here : it may suffice 
to remind the reader that they are believed to be pathologically similar 
diseases, with the important practical distinction that the former occurs 
in early life before the bones are completely ossified, and that the latter 
is a disease of adults producing softening in bones that have been 
hardened and developed. This difference affords a ready explanation of 
the generally resulting varieties of pelvic deformity. 

Effects of Rickets. — Rickets commences very early in life — sometimes, 
it is believed, even in utero. It rarely produces softening of the entire 
bones, and only in cases of very great severity of those parts of the 
bones that have been already ossified. The effects of the disease are 
principally apparent in the cartilaginous portions of the bones, in which 
osseous deposit has not yet taken place. The bones, therefore, are not 
subject to uniform change, and this fact has an important influence in 
determining their shape. Rickety children also have imperfect muscular 
development ; they do not run about in the same way as other children ; 
they are often continuously in the recumbent or sitting posture, and 
thus the weight of the trunk is brought to bear, more than in a state of 
health, on the softened bones. For the same reason, counter-pressure 
through the acetabula is absent or comparatively slight. When, how- 
ever, the disease occurs for the first time in children who are able to run 
about, the latter comes into operation and modifies the amount and nature 
of the deformity. It is to be observed that in rickety children the bones 
are not only altered in form from pressure, but are also imperfectly devel- 
oped ; and this materially modifies the deformity. When ossific matter 
is deposited, the bones become hard and cease to bend under external 
influences, and retain for ever the altered shape they have assumed. 

Effects of Osteo-malacia. — In osteo-malacia, on the contrary, the already 
hardened bones become softened uniformly through all their textures, and 
thus the changes which are impressed upon them are much more regular 
and more easily predicated. It is, however, an infinitely less common 
cause of pelvic deformity than rickets, as is evidenced by the fact that 
in the Paris Maternity, in a period of sixteen years, 402 cases of deform- 
ity due to rickets occurred to 1 due to osteo-malacia. 1 

Their Varying Frequency. — The frequency of both diseases varies 
greatly in different countries and under different circumstances. Rickets 
is much more common amongst the poor of large cities, whose children 
are ill-fed, badly clothed, kept in a vitiated atmosphere, and subjected 
to unfavorable hygienic conditions. Deformities are therefore more com- 
mon in them than in the more healthy children of the upper classes or 
of the rural population. The higher degrees of deformity, necessitating 
the Csesarean section or craniotomy, are in this country of extreme rar- 

1 Stanesco, Becherches cliniques sur les Belrecissements du Bassin. 



DEFORMITIES OF THE PELVIS. 377 

ity, while in certain districts on the Continent they seem to be so fre- 
quent that these ultimate resources of the obstetric art have to be con- 
stantly employed. 

Effects of Ossification of the Pelvic Articulations. — In another class of 
cases the ordinary shape is modified by weight and counter-pressure ope- 
rating on a pelvis in which one or more of the articulations is ossified. 
In this way we have produced the obliquely-ovate pelvis of Naegele or 
the still more uncommon transversely-contracted pelvis of Robert. 

Other Causes of Pelvic Deformity. — A certain number of deformed 
pelves cannot be referred to a modification of the ordinary development- 
al changes of the bones. Amongst these are the deformities resulting from 
spondylolisthesis, or downward dislocation of the lower lumbar verte- 
brae ; from displacements of the sacrum caused by curvatures of the 
spinal column, producing the kyphotic and scoliotic pelves ; or from dis- 
eases of the pelvic bones themselves, such as tumors, malignant growths, 
and the like. 

Equally Enlarged Pelvis. — The first class of deformed pelves to be 
considered is that in which the diameters are altered from the usual 
standard without any definite distortion of the bones ; and such are 
often mere congenital variations in size for which no definite explana- 
tion can be given. Of this class is the pelvis which is equally enlarged 
in all its diameters (pelvis cequabiliter jvsto major), which is of no obstet- 
ric consequence, except inasmuch as it may lead to precipitate labor, and 
is not likely to be diagnosed during life. 

Equally Contracted Pelvis. — The corresponding diminution of all the 
pelvic diameters (pelvis cequabiliter justo minor) may be met with in 
women who are apparently well formed in every respect and whose 
external conformation and previous history gave no indication of the 
abnormality. [*] Sometimes the diminution amounts to half an inch or 
more, and it can readily be understood that such a lessening in the capa- 
city of the pelvis would give rise to serious difficulty in labor. Thus, 
in :> cases recorded by Xaegele a fatal result followed — in '2 alter diffi- 
cult instrumental delivery, and in the third alter rupture of the uterus. 
The equally lessened pelvis, however, is of great rarity. An unusually 
small pelvis may be met with in connection with general small size, as 
in dwarfs. It does not necessarily follow, because a woman is a dwarf, 
that the pelvis is too small for parturition. On the contrary, many such 
women have borne children without difficulty. 

The Undeveloped Pelvis. — In some cases a pelvis retains it< infantile 
characteristics after puberty (Fig. 129). The aormal developmeni of the 
pelvis has been interfered with, possibly, from premature ossification of 

[ ! It is possible tor a lady to be tall, erect, weigh l v <> pounds, and Ik- conspicuous for 
her fine appearance, when she has a justo minor pelvis of very small interior dimen- 
sions. I examined such a patient some years ago, ami not only had Bhe the smallest 

Vagina I have ever explored in a well-urown woman, but it lias recently been found in 

labor that her pelvis would not admit of her being delivered of a full grown living 
child. In fact, it is doubtful whether she could be delivered of one alive much later 
than the seventh month. Married twice and unimpregnated for years, I was BUr prised 
ut her becoming at last pregnant, a- an index finger filled her vagina tightly. After a 
labor of three days, and when the lotus was dead, it wav delivered « nli a crushed lead 
after long and powerful traction, and she made a good recovery. Having large hip-. 
she was under an impression that her pelvis was of corresponding development. I D | 



378 LABOR. 

the different portions of the innominate bones or from arrest of their 
growth from a weakly or rachitic constitution. The measurements of 
these pelves are not always below the normal standard ; they may con- 
tinue to grow, although they have not developed. The proportionate 
measurements of the various diameters will then be as in the infant, and 
the antero-posterior diameter may be longer, or as long, as the transverse, 
the ischia comparatively near each other, and the pubic arch narrow. 
Such a form of pelvis will interfere with the mechanism of delivery, 
and unusual difficulty in labor will be experienced. Difficulties from a 

Fig. 129. 




Adult Pelvis retaining its Infantile Type. 

similar cause may be expected in very young girls. Here, however, 
there is reason to hope that as age advances the pelvis will develop and 
subsequent labors be more easy. 

Masculine or Funnel-shaped Pelvis. — The masculine or funnel-shaped 
pelvis owes its name to its approximation to the type of the male pelvis. 
The bones are thicker and stouter than usual, the conjugate diameter of 
the brim longer, and the whole cavity rendered deeper and narrower at 
its lower part by the nearness of the ischial tuberosities. It is generally 
met with in strong, muscular women following laborious occupations, 
and Dr. Barnes, from his experience in the Royal Maternity Charity, 
says that it chiefly occurs in weavers in the neighborhood of Betlmal 
Green, who spend most of their time in the sitting posture. " The 
cause of this form of pelvis seems to be an advanced condition of ossifi- 
cation in a pelvis which would otherwise have been infantile, brought 
about by the development of unusual muscularity, corresponding to the 
laborious employment of the individual." The difficulties in labor will 
naturally be met with toward the outlet, where the funnel shape of the 
cavity is most apparent. 

Contraction of Conjugate Diameter of Brim. — Diminution of the 
antero-posterior diameter (flattened pelvis) is most frequently limited 
to the brim, and is by far the most common variety of pelvic deformity. 
In its slighter degrees it is not necessarily dependent on rickets, although 



DEFORMITIES OF THE PELVIS. 



379 



when more marked it almost invariably is so. When unconnected with 
rickets, it probably can be traced to some injurious influence before the 
bones have ossified, such as increased pressure of the trunk from carry- 
ing weights in early childhood and the like. By this means the sacrum 
is unduly depressed and projects forward, so as to slightly narrow the 
conjugate diameter. 

Mode of Production in Rickets. — When caused by rickets, the amount 
of the contraction varies greatly, sometimes being very slight, sometimes 
sufficient to prevent the passage of the child altogether, and to m 
tate craniotomy or the Csesarean section. The sacrum, softened by the 
disease, is pressed vertically downward by the weight of the body, its de- 
scent being partially resisted by the already ossified portions of the bone, 
so that the result is a downward and forward movement of the promon- 
tory. The upper portion of the sacral cavity is thus directed more back- 
ward ; but, as the apex of the bone is drawn forward by the attachment 
of the perineal muscles to the coccyx and by the sacro-ischiatic ligaments, 
a sharp curve of its lower part in a forward direction is established. 

Fig-. 130. 




Scolio-rachitic Pelvis. (From a specimen in the Museum of Si. Bartholomew's Hospital. ) 

Occasional Increase of Transverse Diameter. — The depression <>(' the 
sacra] promontory would tend to produce strong traction, through the 
sacro-iliac ligaments, on the posterior end of the sacro-cotyloid beams, and 
thus induce expansion of the iliac bones and consequent increase of tli<' 
transverse diameter of the brim. So an unusual length of the transverse 
diameter is very often described as accompanying this deformity, but prob- 
ably it i- not so often apparent as might otherwise !><• expected, on accounl 
of the imperfect development of the bones generally accompanying rick- 
ets; and Barnes 1 says that in the parts of London where deformities are 
most rife any enlargement of the transverse diameter i- exceedingly rare. 

1 Lectures on Obst. Operatu 



380 LABOR. 

The Scolio-rachitic and Scoliotic Pelvis. — Frequently the sacrum is not 
only depressed, but displaced more or less to one side, most generally to 
the left, thus interfering with the regular shape of the deformed brim. 
This is often the result of a lateral flexion of the spinal column depend- 
ing on the rachitic diathesis, and when well marked is known as the 
scolio-rachitic pelvis (Fig. 130), in which one side of the pelvis, that 
corresponding to the direction of the pelvic curve, is asymmetrical and 
contracted, the ilio-pectineal line being sharply curved inward about the 
site of the sacro-iliac synchondrosis, the symphysis pubis being displaced 
toward the opposite side. A somewhat similar but much less marked 
unilateral asymmetry may exist in cases of scoliosis [*] unconnected with 
rickets, but rarely to a sufficient degree to interfere materially with 
labor. 

Cavity of the Pelvis is generally not Affected. — In most cases of this kind 
the cavity of the pelvis is not diminished in size, and is often even more 
than usually wide. The constant pressure on the ischia which the sitting 
posture of the child entails tends to force them apart, and also to widen 

Fig. 131. 




Rickety Pelvis with Backward Depression of the Symphysis Pubis. 

the pubic arch. Considerable advantage results from this in cases in 
which we have to have perform obstetric operations, as it gives plenty 
of room for manipulation. 

Figure-of-Eight Deformity. — In a few exceptional cases the narrowing 
of the conjugate diameter is increased by a backward depression of the 
symphysis pubis, which gives the pelvic brim a sort of figure-of-eight 
shape (Fig. 131). The most reasonable explanation of this peculiarity 

\} Although hunchbacks frequently have well-formed pelves, it is not uncommon to 
find a deformed spine associated with an asymmetrical pelvis or even a much contracted 
one. Spinal distortion from caries, especially in the lumbar region, is thus associated, 
and the pelvic deformity will be increased if there has been coxalgia, either double or 
single, or if from any cause one leg should be shorter than the other. In the records 
of the Porro operation we find under "the cause of difficulty," " pseudo-osteo-malacia," 
" lumbo-dorsal kyphosis," "kyphoscoliosis" etc. Pseudo-osteo-malacia is the result of 
rickets in a walking child, the form of pelvis being changed mechanically, as in osteo- 
malacia. Lumbo-dorsal kyphosis may or may not give rise to the kyphotic pelvis, as 
much will depend upon the extent of vertebral caries. Scoliosis is apt to result from 
rickets, and may be associated with lordosis. 

Scoliosis, from OKo?.t.oc, crooked — a distortion of the spine to one side. 

Lordosis, from topdoc, curved— applied particularly to the forward bending of the 
spine. 

Kyphosis, from i(v<j>oote, gibbous, arched, or vaulted — a hump or backward curvature 
of the spine. — Ed.] 



DEFORMITIES OF THE PELVIS. 



381 



seems to be that it is the result of the muscular contraction of the recti 
muscles at their point of attachment, when the centre of gravity of the 
body is thrown backward on account of the projection of the sacral pr< >m- 
ontory. Sometimes, also, the antero-posterior diameter of the cavity is 
unusually lessened by the disappearance of the vertical curvature of 
the sacrum, which, instead of forming a distinct cavity, is nearly flat 
(Fig. 132). 

Spondylolisthesis. — In a few rare cases, to which attention was first 
called in 1853 by Kilian of Bonn, a very formidable narrowing of the 
conjugate diameter of the pelvic brim is produced by a downward dis- 
placement of the fourth and fifth lumbar vertebrae, which become dislo- 
cated forward, or, if not actually dislocated, at least separated from their 
several articulations to a sufficient extent to encroach very seriously on 
the dimensions of the pelvic inlet. This condition is known as spondyl- 
olisthesis[ l ] (Fig. 133). 

Fig. 132. 





Flatness of Sacrum, with Narrowin 

Pelvic Cavity. 



Pelvis Deformed by Spondylolisthesis. 
(After Kilian.) 



The effect of this is sufficiently obvious, for the projection of the 
lumbar vertebrae prevents the passage of the child. To such an extent 
is 6bstruction thus produced that in the majority of the recorded cases 
the Csesarean section was necessary. The true conjugate diameter, that 
between the promontory of the sacrum and the symphysis pubis, ifi 
increased rather than diminished; but, for all practical purposes, the 
condition is similar to extreme narrowing of the conjugate from rick- 
ets, for the bodies of the displaced vertebrae project into and obstruct the 
pelvic brim. 

The cause of this deformity seem- to be different in diflferenl cases. 
In some it seems to have been congenital, and in others to have depended 
on some antecedent disease of the hone-, such as tuberculosis or scrofula, 
producing inflammation and softening of the connection between the last 
lumbar vertebra and the sacrum, thus permitting downward displace- 
ment of the bones. Lambl believed that it generally followed spina 

[ ! From oTiovdv/.ng, the vertebra, and oXur&ijfftf, :l Blipping or slid ii I D 



382 



LABOR. 



bifida which had become partially cured, but which had produced 
deformity of the vertebrae and favored their dislocation. Brodhurst, 1 
on the other hand, thinks that it most probably depends on rachitic 
inflammation and softening of the osseous and ligamentous structures, 
and that it is not a dislocation in the strict sense of the word. This con- 
dition has recently been made the subject of special study by Dr. Franz 
Neugebauer, 2 who believes that the forward displacement is never the 
result of antecedent disease of the bones, but depends either on congeni- 
tal want of development of the vertebral arches or on traumatism, such 
as fracture of the articular processes, which allows the weight of the 
trunk to displace the body of the last lumbar vertebra forward, either 
partially or entirely. 

[We are indebted to Kilian of Germany for the first careful investi- 
gation of the true character of spondylolisthetic deformity, although the 

credit of initial mention is due to 
Fig. 134. Rokitansky of Austria, who wrote 

in 1839, antedating the monograph 
of the former (1853) by fourteen 
years. No special mention is made 
of this peculiar lordosis by Roki- 
tansky in his Manual of Patholog- 
ical Anatomy in 1844, but in his 
Lehr buck (1855) it is given, with 
due credit to Kilian. During the 
thirty years that have passed since 
Kilian prepared his paper from ob- 
servations made upon three pelves 
which had been obtained from sub- 
jects in whom the Caesarean section 
had proved fatal, one of them after 
a second operation, there have ap- 
peared numerous monographs and 
descriptions of cases, much the most 
valuable and extensive of which are 
those by Dr. Franz Ludwig JNeuge- 
bauer of Warsaw and Dr. A. Swedelin of St, Petersburg, the latter of 
whom furnishes the bibliography of the subject. These valuable papers 
cover 153 and 40 pages, respectively, of the Archiv fur Gynwkologie, 
Berlin, the former having 87 illustrations and the latter 7, and may be 
found in vols, xix., xx., xxi., and xxii., for 1882-84. 

The cause or causes of spondylolisthesis have not as yet been very 
satisfactorily determined. The disease in some of its features would 
appear to be a form of local malacosteon or of osteitis deformans, differ- 
ing from the former in the fact that it may occur without pain, that the 
general health may not be impaired, and that the subjects may be nulli- 
parous ; which last is exceedingly rare in malacosteon. In the lordosis 
of ordinary malacosteon there is no sliding of the last lumbar vertebra, 
or this peculiar deformity would be much less infrequent. As it is, 

1 Obat. Trans., vol. vi. p. 97. 

2 Contribution a la Pathogenie du Bassin Vide par le Glissement vertebral, Paris, 1884. 




[Spondylolisthesis. (After Neugebauer.)] 



DEFORMITIES OF THE PELVIS. 383 

after an extended search by a number of writers, we are limited to the 
study of 17 pelves and 25 clinical cases: the photographic process has 
also made us familiar with the contour of body produced by the disease. 
The effect of the spinal slipping and anterior curvature of the loins is to 
shorten the trunk of the woman, cause a pouch-like protrusion of her 
abdomen, and elevate and widen the hips. As the pelvis is not col- 
lapsed, there is no alteration in the pubes or hip-joints, and as many of 
the subjects are robust, their change of form is quite perceptible even in 
full dress. The only true test of the condition is the discovery per vagi- 
nam of the overhanging fifth lumbar vertebra, with which may also be 
felt the pulsation of the primitive iliacs, and in extreme eases even the 
bifurcation of the aorta. The shortening of the abdominal cavity forces 
the pregnant uterus into an extreme anterior obliquity, which, by inter- 
fering with the line of its expulsive action, adds to the difficulty pro- 
duced by the narrowing of the conjugate diameter. 

We have a special interest in the study of this deforming malady 
from the fact that one of the cases on record occurred in San Francisco 
under the care of Prof. James Blake of Toland Medical College, and 
was reported by him in the Pacific Med. and Surg. Journal of Feb., 1 <S(i7. 
The subject of this disease was married at 15 years of age, at which 
time she weighed 101 pounds, but increased to 199 pounds by the time 
her first child was born. Her first and second labors were tedious, but 
the children were born alive; she aborted of another foetus at four 
months, and later was delivered at maturity of four others, all dead, the 
conjugate space in the seventh labor being computed at 3^- inches. This 
labor was so difficult that it was decided, in the event of another preg- 
nancy, to bring on labor prematurely. She became pregnant for the 
eighth time at the age of 26, when she weighed 220 pounds. Labor 
was induced in the seventh month, but the foetus was lost, as it weighed 
nearly six pounds and the lumbo-pubic space was reduced to 3 inches. 
This woman is said to have unolergone the change in her vertebra' with- 
out pain or sign of ill-health, and to have retained a remarkable activity 
for her weight. After her eighth delivery she was up in six days, and 
down stairs in ten. The history of this case would indicate that the 
deforming process must have been slowly progressing during more than 
ten years. 

In contrast with this painless case in a multipara we have the oppo- 
site in a nullipara, reported by Dr. Olshausen of Halle. The disease 
commenced in his patient when a girl of IS with severe pains in the 
sacrum and hips, as in malacosteon. She had not had rickets in child- 
hood, had enjoyed good health up this time, and was quite straight. As 
her disease progressed she found on awaking one morning thai she could 
not straighten her spine, and was forced to walk with her body benl 
forward. She was put under medical treatment at the surgical clinic J 
had no fever, and in time ceased to sillier, and was discharged. Becom- 
ing pregnant at the age of 24, Dv. Olshausen delivered her in 1863 bj 
the Caesarean section: the child lived, but she was losl on tin 1 fourth 
day by peritonitis. The lumbo-pubic diameter was found to measure •"> 
inches, and the line of the conjugate struck the lower margin of the third 
lumbar vertebra. 



384 LABOR. 

Spondylolisthesis must not be confounded with that form of lumbar 
lordosis in which the fifth vertebra retains its proper articulation with 
the top of the sacrum, or with that produced by lumbo-sacral caries. 
In true spondylolisthetic deformity the superior strait is not distorted, 
but is encroached upon from above by the sagging down of the lumbar 
vertebrae, and particularly by the slipping forward of the entire body of 
the fifth. A vertical section of the lumbo-sacral spine will show that 
the displaced vertebra has in some cases been thinned, and that in others 
the top of the sacrum has been compressed and new bone thrown out to 
give additional support to the dislodged vertebra. To accomplish this 
without paralysis, there must necessarily be some softening of bone and 
cartilage, with relaxation of ligaments and a gradual giving way, espe- 
cially at the sacro-vertebral articulation, with an enlargement of the 
spinal canal in the slipping portion to avoid pinching the spinal nerve. 
Certainly, the clinical history of some of the cases cannot be explained, 
except under the belief that there has been some antecedent bone disease 
affecting at least the articulating processes. Prof. Blake attributed the 
deformity in his case to a dislocation produced by a rapid increase in 
weight ; but hundreds of women are subjected to the same cause and 
remain straight ; and, besides, his patient must have had a very gradual 
dislocation. The theory of fracture of the articular processes is not at 
all satisfactory, as the gravity of the symptoms is not indicative of such 
an accident having occurred ; neither is that of a congenital defect in the 
said processes, although this may account for some of the cases, espe- 
cially if we admit that the defective articulations may become insufficient 
to support the weight of the trunk by reason of a weakening produced 
by disease. — Ed.] 

Spondylolizema. — A somewhat analogous deformity has been described 
by Hergott 1 under the name of spondylolizema. In this the bodies of 
the lower lumbar vertebrae having been destroyed by caries, the upper 
lumbar vertebrae sink downward and forward, so as to obstruct the pel- 
vic inlet and prevent the engagement of the foetus. It thus differs from 
spondylolisthesis, in which there is dislocation, but not destruction, of 
the bodies of the lower lumbar vertebrae. 

Narrowing of the Oblique Diameter. — The most marked examples of 
narrowing of both oblique diameters depend on osteo-malacia. In this 
disease, as has already been remarked, the bones are uniformly softened, 
and the alterations in form are further influenced by the fact that the 
disease commences after union of the separate portions of the ossa inno- 
minata has been completely effected. The amount of deformity in the 
worst cases is very great, and frequently renders delivery impossible 
without the Caesarean section. Sometimes the softening of the bones 
proves of service in delivery, by admitting of the dilatation of the con- 
tracted pelvic diameter by the pressure of the presenting part or even 
by the hand. Some curious cases are on record in which the deformity 
was so great as to apparently require the Caesarcan section, but in 
which the softened bones eventually yielded sufficiently to render this 
unnecessary. 

Mode of Production in Osteo-malacia. — The weight of the body 

1 Arch, de Tocologie, 1877. 



DEFORMITIES OF THE PELVIS. 



385 



depresses the sacrum in a vertical direction, and at the same time com- 
presses its component parts together, so as to approximate the base and 
apex of the bone, and narrow the conjugate diameter of the brim by 



Fig. 135. 




Osteo-malacic Pelvis.^] 

causing the promontory to encroach upon it. The most characteristic 
changes are produced by the pushing inward of the walls of the pelvis 
at the cotyloid cavities in consequence of pressure exerted at these points 
through the femora. The effect of this is to diminish both oblique 
diameters, giving the brim somewhat the shape of a trefoil or an ace of 
clubs. The sides of the pubes are at the same time approximated, and 
may become almost parallel, and the true conjugate may be even length- 
ened (Fig. 135). The tuberosities of the ischia are also compressed 
together with the rest of the lateral pelvic wall, so that the outlet is 
greatly deformed as well as the brim (Fig. 136). 

Fig. 136. 




Extreme Degree of Osteo-malacic Deformity. 

\_(Mco-mal<t<-'i<t not an American /)/*<'('*<■. — In not one of the 134 
Cesarean cases of the United States was the operation performed for 
this form of deformity. In a few instances the malady has been found 



[* This form is known :is rostrate or beaked, Ed. \ 



25 




386 LABOR. 

in foreigners, and the forceps or craniotomy used in their delivery. 

Many obstetricians of large experience have never seen a case, and I do 

not know of an instance of extreme rostration of the pelvis having been 

met with in this country. — Ed.] 

Obliquely-contracted Pelvis. — That form of deformity in which one 

oblique diameter only is lessened has received considerable attention, 

from having been made the subject of 
special study by JSTaegele, and is gener- 
ally known as the obliquely-contracted 
pelvis (Fig. 137). It is a condition 
that is very rarely met with, although 
it is interesting from an obstetric point 
of view, as throwing considerable light 
on the mode in which the natural de- 
velopment of the pelvis is effected. It 
is difficult to diagnose, inasmuch as 
there is no apparent external deform- 
ity, and probably it has never, in fact, 
been detected before delivery. It has 

Obliquely-contracted Pelvis. • • n -, \ T • , 

(After Duncan.) a very serious influence on labor : JLitz- 

mann found that out of 28 cases of this 

deformity, 22 died in their labors and 5 more in subsequent deliveries. 

The prognosis, therefore, is very formidable, and renders a knowledge 

of this distortion, rare though it be, of importance. 

Its essential characteristic is flattening and want of development of 
one side of the pelvis, associated with anchylosis of the corresponding 
sacro-iliac synchondrosis. The latter is probably always present, and it 
seems to be most generally a congenital malformation. The lateral half 
of the sacrum on the same side, and the entire innominate bone, are much 
atrophied. The promontory of the sacrum is directed toward the diseased 
side, and the symphysis pubis is pushed over toward the healthy side. 

The main agent in the production of this deformity is the absence of 
the sacro-iliac joint, which prevents the proper lateral expansion of the 
pelvic brim on that side, and allows the counter-pressure, through the 
femur, to push in the atrophied os innominatum to a much greater 
extent than usual. The chief diminution in the length of the pelvic 
diameter is between the ilio-pectineal eminence of the affected side and 
the healthy sacro-iliac joint, while the oblique diameter between the 
anchylosed joint and the healthy os innominatum is of normal length. 

[Another form of obliquely-contracted pelvis is the result of coxalgic 
atrophy of one ilium, produced by hip disease in early childhood, the 
side of the pelvis being stunted in growth, as well as the whole extrem- 
ity attached to it. Two Caesarean operations have been performed in 
the United States in cases having this form of deformity. — Ed.] 

Narrowing of ihe Transverse Diameter. — Transverse contraction of 
the pelvic brim is very much less common than narrowing of the con- 
jugate diameter. It most frequently depends on backward curvature 
of the lower parts of the spinal column in consequence of disease of the 
vertebrae. This form of deformed pelvis is generally known as the 
kyphotic (Fig. 138). The effect of the spinal curvature is to drag the 



DEFORMITIES OF THE PELVIS. 



387 



promontory of the sacrum backward, so that it is high up and out of 
reach. By this means the antero-posterior diameter of the brim is 
increased, while the transverse is lessened; the relative proportion 
between the two is thus reversed. While the upper portion of the 

Fig. 138. 




Kyphotic Pelvis. 
(From a specimen in the Museum of St. Bartholomew's Hospital.) 

sacrum, is displaced backward, its lower end is projected forward, bo 
that the antero-posterior diameters of the cavity and outlet are consider- 
ably diminished. The ischial tuberosities are also nearer to each other, 
and the pubic arch is narrowed. Obstruction to deli very will be chiefly 
met with at the lower parts and outlet of the pelvic cavity, for, although 
the transverse diameter of the brim is narrowed, there is generally suf- 
ficient space for the passage of the head. 

Robert's Pelvis. — Another form of transversely-contracted pelvis is 
known- as Roberts pelvis (Fig. 139), having been firsl discovered by 

Robert of Coblentz. Ii is in fad a 
Fig- i ; double obliquely-contracted pelvis, de- 

pending on anchylosis of both sacro- 
iliac joints, and consequenl defective 
development of the innominate bones. 
The shape of the pelvic brim Is mark- 
edly oblong, and the sides of the pel- 
vis are more or less parallel with each 

other. The out Id i- also much con- 
tracted transversely. The amount of 
obstruction is \<t\ great, so that, 
cording to Schroeder, out of 7 w<ll 

authenticated cases tin < toe arearj sec 

Robert's or Double Obliquely-contracted f ; ; i ; , ; 

Pelvis. (After iWan.) 1l,,n u:l ^ required iii '». 




388 



LAB OB. 



Fig. 140. 



[The Porro-Csesarean operation has only been called for in one instance, 
by reason of this rare condition. Prof. Josef Spath of Vienna operated 
with success to mother and child on March 7, 1883. The c. v. measured 
3f inches, and the bis-ischiatic only 1 inch. — Ed.] 

Deformity from Old-standing Hip-joint Disease. — Another cause of 
transverse deformity occasionally met with is luxation of the head of 
the femur, depending on old-standing joint-disease. The head of the 
femur in this case presses on the innominate bone at the site of disloca- 
tion, and the result is that the iliac fossa on the affected side, or both if 
the accident happens on both sides, is pushed inward, the transverse 
diameter of the brim being lessened. The tuberosity of the ischium is, 
however, projected outward, so that the outlet of the pelvis is increased 
rather than diminished. 

Deformity from Tumors, Fractures, etc. — Obstruction of the pelvic 
cavity from exostoses or other forms of tumors growing from the bones 

is of great rarity (Fig. 140). It may, 
however, produce very serious dys- 
tocia. Several curious examples are 
collected in Mr. Wood's article on 
the pelvis, in some of which the ob- 
struction was so great as to necessi- 
tate the Cesarean section, [*] Some 
of these growths were true exostoses, 
and, according to Stadtfeldt, 2 these 
are commonly found in pelves that 
are otherwise contracted ; others, os- 
teo-sarcomatous tumors attached to 
the pelvic bones, most generally the 
upper part of the sacrum ; and others 
were malignant. In some cases spicu- 
le of bone have developed about the 
linea ilio-pectinea or other parts of 
the pelvis, which may not be sufficient 
to produce obstruction, but which 
may injure the uterus, or even the 
foetal head, when they are pressed upon them. Irregular projections 
may also arise from the callus of old fractures of the pelvic bones. All 
such cases defy classification, and differ so greatly in their extent and in 
their effect on labor that no rules can be laid down for them, and each 
must be treated on its own merits. 

Effects of Contracted Pelvis in Labor. — The effects of pelvic contrac- 
tions on labor vary, of course, greatly with the amount and nature of 
the deformity ; but they must always give rise to anxiety, and in the 
graver degrees they produce the most serious difficulties we have to con- 
tend with in the whole range of obstetrics. 

Nature of Uterine Action in Pelvic Deformity. — In the lesser degrees, 

[ x Ten Cesarean operations in the United States saved four of the cases and five 
children. One fatal case had been in labor two weeks; one, four days; two, three 
days ; and one, two days. — Ed.] 

2 Obstetrical Journal, July, 1879. 




Bony Growth from Sacrum obstructing the 
Pelvic Cavity. 



DEFORMITIES OF THE PELVIS. 389 

in which the proportion between the presenting part and the pelvis is 
only slightly altered, Ave may observe little abnormal beyond a greater 
intensity of the pains and some protraction of the labor. It is gener- 
ally observed that the uterine contractions are strong and forcible in 
cases of this kind, probably because of the increased resistance they have 
to contend against ; and this is obviously a desirable and conservative 
occurrence, which may of itself suffice to overcome the difficulty. The 
first stage, however, is not unfrequently prolonged and the pains are 
ineffective, for the head does not readily engage in the brim, the uterus 
is more mobile than in ordinary labors, and it probably acts at a dis- 
advantage. 

Risk to the Mother. — In the more serious cases the mother is subjected 
to many risks, directly proportionate to the amount of obstruction and 
the length of the labor. The long-continued and excessive uterine action 
produced by the vain endeavors to push the child through the contracted 
pelvic canal, the more or less prolonged contusion and injury to which 
the maternal soft parts are necessarily subjected (not unfrequently end- 
ing in inflammation and sloughing with all its attendant dangers), and 
the direct injury which may be inflicted by the measures we are com- 
pelled to adopt for aiding delivery (such as the forceps, turning, crani- 
otomy, or Cesarean section), — all tend to make the prognosis a matter 
of grave anxiety. 

Risk to the Child. — Xor are the dangers less to the child, and a very 
large proportion of stillbirths will always be met with. The infantile 
mortality may be traced to a variety of causes, the most important being 
the protraction of the labor and the continuous pressure to which the 
presenting part is subjected. For this reason, even in cases in which the 
contraction is so slight that the labor is terminated by the natural powers, 
it lias been estimated that 1 out of every 5 children is stillborn ; and as 
the deformity increases in amount, so, of course, does the prognosis to 
the child become more unfavorable. 

Frequent Occurrence of Prolapse of the Cord. — Prolapse of the um- 
bilical cord is of very frequent occurrence in cases of pelvic deformity, 
the tendency to this accident being traceable to the fact of the head not 
entering and occupying the upper strait of the pelvis as in ordinary 
labors, and thus leaving a space through which the cord may descend. 
So frequently is this complication met with in pelvic deformity thai 
Stanesco 1 found it had happened as often as 59 time- in II I labors; and 
when the dangers of prolapsed funis are added to those of protracted 
labors, it is hardly a matter of surprise that the occurrence should, under 
such circumstances, almosl always prove fetal to the child. 

Injury to Child's Head. — The head of the child is also liable t<» injury 
of a more or less grave character from the compression t<- which it is 
subjected, especially by the promontory of* the sacrum. I ndepindnii Iv 

of the transient effects of undue pressure (temporary alterati f the 

shape of the bones and bruising of the scalp), there 19 "Inn m.t with a 
more serious depression of the bones of the skull produced by the sacral 
promontory. This is most marked in cases in which the head has been 
forcibly dragged past the projecting hone by the forceps or after turning. 

1 Op. eit., p. 94. 



390 LABOR. 

The amount of depression varies with the degree of contraction ; but 
sometimes, were it not for the yielding of the bones of the foetal skull 
in this way, delivery, without lessening the size of the head by perfora- 
tion, would be impossible. Such depressions are found at the spot 
immediately opposite the promontory, generally at the side of the skull 
near the junction of the frontal and parietal bones. Sometimes there is 
a slight permanent mark, but more often the depression disappears in a 
few days. The prognosis to the child is, however, grave when the con- 
traction has been sufficient to indent the skull, for it has been found that 
50 per cent, of jthe children thus marked died either immediately or 
shortly after labor. 1 

Course of Labor. — The means which nature takes to overcome these 
difficulties are well worthy of study, and there are certain peculiarities in 
the mechanism of delivery, when pelvic deformities exist, which it is of 
importance to understand, as they guide us in determining the proper 
treatment to adopt. 

Frequency of llalpresentation. — Malpresentations of the foetus are of 
much more frequent occurrence than in ordinary labors — partly because 
the head does not engage readily in the brim, but, remaining free above 
it, is apt to be pushed away by the uterine contractions ; and partly 
because of the frequent alteration of the axis of the uterine tumor. The 
pendulous condition of the abdomen in cases of pelvic deformity is often 
very obvious, so that the fundus is sometimes almost in a line with the 
cervix, and thus transverse or other abnormal positions are very fre- 
quently met with. It is to be noted, however, that we cannot regard 
breech presentations as so unfavorable as in ordinary labors, for the pres- 
sure from the contracted pelvis is less likely to be injurious when applied 
to the body than to the head of the child ; and, indeed, as we shall pres- 
ently see, the artificial production of these presentations is often advisable 
as a matter of choice. 

Mechanism of Delivery in Head Presentations. — The mode in which 
the head passes naturally through a contracted pelvis is in some respects 
different from the ordinary mechanism of delivery in head presenta- 
tions, and has been carefully worked out by Spiegelberg and other Ger- 
man obstetricians. 

The means which nature adopts to overcome the difficulty are differ- 
ent in cases in which there is a marked narrowing of the conjugate 
diameter of the brim, and in those in which there is a generally-con- 
tracted pelvis. 

In Contracted Brim. — In the former and more common deformity the 
head lies at the brim with its long occipito- frontal diameter in the trans- 
verse diameter of the pelvis, and, as both parietal bones cannot entei 
the contracted brim, it lies with one parietal bone on a much lower level 
than the other, in the large majority of cases that nearest the pubes being 
most depressed, so that the sagittal suture is felt high up near the prom- 
ontory of the sacrum. As labor advances, if the contraction is not too 
great to be insuperable, the anterior fontanelle comes much more within 
reach than in ordinary labor, while at the same time the occipital por- 
tion of the head is shoved to the side of the pelvis, so that its narrow 

1 Schroeder, op. cit., p. 256. 



DEFORMITIES OF THE PELVIS. 391 

bi-temporal diameter engages in the contracted conjugate. At this stage, 
on examination, it will be found — supposing we have to do with a case 
in which the occiput points to the left side of the pelvis — that the ante- 
rior fontanelle is lower than the posterior, and to the right, the bi-tem- 
poral diameter of the head is engaged in the conjugate diameter of the 
brim (as the smallest diameter of the skull, there is manifest advantage 
in this), and that the bi-parietal diameter and the largest portion of the 
head point to the left side. The sagittal suture will be felt running 
across in the transverse diameter of the brim, but nearer to the sacrum, 
the head being placed obliquely. As the head is forced down by the 
uterine contractions, the parietal bone, which is resting on the promon- 
tory, is pushed against it, so that the sagittal suture is forced more into 
the true transverse diameter of the pelvic brim and approaches nearer 
to the pubes. The next step is the depression of the head, the occiput 
undergoing a sort of rotation on its transverse axis, so that it readies a 
plane below the brim. When this is accomplished, the rest of the head 
readily passes the obstruction. The forehead now meets with the resist- 
ance of the pelvic walls, the posterior fontanelle descends to a lower level, 
and, as the cavity of the pelvis in cases of antero-posterior contraction 
of the brim is generally of normal dimensions, the rest of the labor is 
terminated in the usual way. 

In Gene rally-contracted Pelvis. — In the generally-contracted pelvis 
the head enters the brim with the posterior fontanelle lowest, and it is 
after it has engaged in it that the resistance to its progress becomes 
manifest. The result is, therefore, an exaggeration of what is met witli 
in ordinary cases. The resistance to the anterior or longer arm of the 
lever is greater than that to the occipital or shorter, and therefore the 
flexion of the head becomes very marked. The posterior fontanelle is 
consequently unusually depressed, and the anterior quite out of reach. 
So the head is forced down as a wedge, and its further progress must 
depend upon the amount of contraction. If this be not too great, the 
anterior fontanelle eventually descends, and delivery is completed in the 
usual way. Should the contraction be too much to permit of this, the 
head becomes jammed in the pelvis and diminution of its size may 1><' 
essential. 

In cases of deformity of the conjugate diameter, combined with 
general contraction of the pelvis, the mechanism partakes of the pecu- 
liarities of both these classes to a greater or less extent, in proportion to 
the preponderance of one or other species of deformity, 

Diagnosis. — It rarely happens thai deformities of the pelvis, except 
of the gravest kind, are suspected before labor has actually commenced, 
and therefore we are not often called upon to give an opinion as to the 
condition of the pelvis before delivery. Should we he, there are various 
circumstances which may aid us in arriving at a correcl conclusion. 
Prominent among them is the history of the patient in childhood [f 
she is known to have suffered from rickets in early life, more especially 
if the disease has left evident traces in deformities of the Limbs or in a 
dwarfed and stunted growth or in curvature of the spine, there will !»' 
strong presumptive evidence of pelvic deformity ; a markedly pendulous 
state of the abdomen may also tend to confirm the suspicion. Nothing 



392 LABOR. 

short of a careful examination of the pelvis itself will, however, clear up 
the point with certainty ; and even by this means to estimate the precise 
degree of deformity with accuracy requires considerable skill and practice. 
The ingenuity of practitioners has been much exercised — it might per- 
haps be justly said wasted — in the invention of various more or less 
complicated pelvimeters for aiding us in obtaining the desired object. It 
is, however, pretty generally admitted by all accoucheurs that the hand 
forms the best and most reliable instrument for this purpose — at any 
rate, as regards the interior of the pelvis — although a pair of callipers, 
such as Baudelocque's well-known instrument, is essential for accurately 
determining the external measurements. The objections to all internal 
pelvimeters, even those most simple in their construction, are their cost 
and complexity and the impossibility of using them without pain or 
injury to the patient. 

External Measurements. — It was formerly thought that by measuring 
the distance between the spinous processes of the sacrum and the sym- 
physis pubis, and subtracting from it what we judge to be the thickness 
of the bones and soft parts, we might arrive at an approximate estimate 
of the measurement of the conjugate diameter of the pelvic brim. It is 
now admitted that this method can never be depended on, and that, 
taken by itself, it is practically useless. A change in the relative length 
of other external measurements of the pelvis is, however, often of great 
value in showing the existence of deformity internally, although not in 
judging of its amount. The measurements which are used for this pur- 
pose are between the anterior-superior spines of the ilia and between the 
centres of their crests, averaging respectively 10 and 11 inches. Accord- 
ing to Spiegelberg, these measurements may give one of three results : 

1. Both may be less than they ought to be, but the relation of one to 
the other remains unchanged. 

2. That between the crests is not, or is at most very little, diminished, 
but that between the spines is increased. 

3. Both are diminished, but at the same time their mutual relation is 
not normal, the distance between the spines being as long, if not longer, 
than that between the crests. 

No. 1 denotes a uniformly-contracted pelvis ; No. 2, a pelvis simply 
contracted in the conjugate diameter of the brim, and not otherwise 
deformed ; No. 3, a pelvis with narrowed conjugate and also uniformly 
contracted, as in the severe type of rachitic deformity. If, however, 
both these measurements are of average length, and the distance between 
the crests is about 1 inch greater than between the spines, the pelvis is 
normal. 

Besides the above, some information may be obtained by the measure- 
ment of the external conjugate diameter, which averages 7f inches. 
This may be taken by placing one point of the callipers in the depres- 
sion below the spine of the last lumbar vertebra, the other at the centre 
of the upper edge of the symphysis pubis. If the measurement be dis- 
tinctly below the average — not more, for example, than 6.3 inches — we 
may conclude that there is a narrowing of the antero-posterior diameter 
of the brim, the extent of which Ave must endeavor to ascertain by other 
means. 



DEFORMITIES OF THE PELVIS. 



393 



For the purpose of making these measurements, Baudelocque's compos 
cVepaisseur can be used, or Dr. Lazarewitch's elegant universal pelvim- 
eter, which can be adopted also for internal pelvimetry ; but in the 
absence of these special contrivances an ordinary pair of callipers, such 
as are used by carpenters, can be made to answer the desired object. 

Internal Measurements. — These external measurements must be cor- 
roborated by internal, chiefly of the antero-posterior diameter, by which 
alone we can estimate the amount of the deformity. We endeavor to 
find, in the first place, the length of the inclined conjugate between the 
lower edge of the symphysis pubis and the promontory of the sacrum, 
which averages about half an inch more than the true conjugate. This 
is best done by placing the patient on her back with the hips well raised. 
The index finger of the right hand is then introduced into the vagina, 
and the perineum is pressed steadily backward, so as to overcome the 
resistance it offers. If the tip of the finger can reach the promontory of 
the sacrum, its radial side is raised so as to touch the lower edge of the 
pubes. A mark is made with the nail of the index of the left hand on 
that part of the examining finger which rests under the symphysis, and 
then the distance from this to the tip of the finger, less half an inch, 
may be taken to indicate the measurement of the true conjugate of the 
brim. Various pelvimeters have been devised to make the same meas- 
urements, such as Lumley Earle's, Lazarewitch's (which is similar in 
principle), and Van HuevePs; the best and simplest, I think, is that 
invented by Dr. Greenhalgh (Fig. 141). It consists of a movable rod 
attached to a flexible band of metal 
which passes around the palm of 
the examining hand. At the distal 
end of the rod is a curved portion 
which passes over the radial edge 
of the index finger. The examina- 
tion is made in the usual way, and 
when the point of the finger is rest- 
ing on the promontory of the sacrum 
the rod is withdrawn until it is 
arrested by the posterior surface of 
the symphysis, the exact measure- 
ment of the inclined conjugate being 
then read off the scale. 

It is to be remembered that this 
procedure is useless in the' slighter 
degrees of contraction in which the 
promontory of the sacrum cannot 
beeasily reached. Dr. Ramsbotham 
proposed to measure the conjugate 
by spreading out the index and 
middle fingers internally, the tip of 
one resting on the promontory, the 
other behind the symphysis pubis, and then withdraw ing tin-in in the 
same position and measuring the distance between them. Thia manoeu- 
vre I believe to be impracticable. 



Fig. 141. 




Greenhalgb'a ivi\ tmet< 



394 LABOR. f 

Whenever, in actual labor, we wish to ascertain the condition of the 
pelvis accurately, the patient should be anaesthetized, and the whole hand 
introduced into the vagina (which could not otherwise be done without 
causing great pain), and the proportions of the pelvis and the relations 
of the head to it thoroughly explored ; and if what has been said as to 
the mechanism of delivery in these cases be borne in mind, this may aid 
us in determining the kind of deformity existing. In this way contrac- 
tions about the outlet of the pelvis can also be pretty generally made out. 

Mode of Diagnosing the Oblique Pelvis. — The obliquely-contracted 
pelvis cannot be determined by any of these methods, but certain exter- 
nal measurements, as Naegele has pointed out, will readily enable us to 
recognize its existence. It will be found that measurements which in 
the healthy pelvis ought to be equal are unequal in the obliquely-distorted 
pelvis. The points of measurement are chiefly : (1) From the tuber- 
osity of the ischium on one side to the posterior-superior spine of the 
ilium on the other ; (2) from the anterior-superior iliac spine on the one 
side to the posterior-superior on the opposite ; (3) from the trochanter 
major of one side to the posterior-superior iliac spine on the other ; (4) 
from the lower edge of the symphysis pubis to the posterior-superior 
iliac spine on either side ; (5) from the spinous process of the last lum- 
bar vertebra to the anterior-superior spine of the ilium on either side. 

If these measurements differ from each other by half an inch to an 
inch, the existence of an obliquely-deformed pelvis may be safely diag- 
nosed. The diagnosis can be corroborated by placing the patient in the 
erect position and letting fall two plumb-lines — one from the spines of 
the sacrum, the other from the symphysis pubis. In a healthy pelvis 
these will fall in the same plane, but in the oblique pelvis the anterior 
line will deviate considerably toward the unaffected side. 

Treatment. — The proper management of labor in contracted pelvis is, 
even up to this time, one of the most vexed questions in midwifery, not- 
withstanding the immense amount of discussion to which it has given 
rise ; and the varying opinions of accoucheurs of equal experience afford 
a strong proof of the difficulties surrounding the subject. This remark 
applies, of course, only to the lesser degree of deformity, in which the 
birth of a living child is not hopeless. When the antero-posterior diam- 
eter of the brim measures from 2|^ to 3 inches, it is universally admitted 
that the destruction of the child is inevitable, unless the pelvis be so 
small as to necessitate the performance of the Csesarean section. But 
when it is between 3 inches and the normal measurement, the compara- 
tive merits of the forceps, turning, and the induction of premature labor 
form a fruitful theme for discussion. With one class of accoucheurs the 
forceps is chiefly advocated, and turning admitted as an occasional 
resource when it has failed ; and this indeed, speaking broadly, may be 
said to have been the general view held in this country. More recently 
we find German authorities of eminence, such as Schroeder and Spiegel- 
berg, giving turning the chief place, and condemning the forceps alto- 
gether in contracted pelvis, or at least restricting its use within very nar- 
row limits. More strangely still, we find of late that the induction of 
premature labor, on the origination and extension of which British 
accoucheurs have always prided themselves, is placed without the pale, 



DEFORMITIES OF THE PELVIS. 395 

and spoken of as injurious and useless in reference to pelvic deformities. 
To see our way clearly amongst so many conflicting opinions is by no 
means an easy task, and perhaps we may best aid in its accomplishment 
by considering separately the three operations in so far as they bear on 
this subject, and pointing out briefly what can be said for and against 
each of them. 

The Forceps. — In England and in France it is pretty generally admit- 
ted that in the slighter degrees of contraction the most reliable means of 
aiding the patient is by the forceps. It should be remembered that the 
operation under such circumstances is always much more serious than in 
ordinary labors simply delayed from uterine inertia, when there is ample 
room and the head is in the cavity of the pelvis ; for the blades have to 
be passed up very high, often when the head is more or less movable 
above the brim, and much more traction is likely to be required. For 
these reasons artificial assistance, when pelvic deformity is suspected, is 
not to be lightly or hurriedly resorted to. Nor, fortunately, is it always 
necessary, for if the pains be sufficiently strong, and the contraction not 
too great to prevent the head engaging at all, after a lapse of time it 
will become so moulded in the brim as to pass even a considerable ob- 
struction. In all cases, therefore, sufficient time must be given for this ; 
and if no suspicious symptoms exist on the part of the mother — no ele- 
vation of temperature, dryness of the vagina, rapid pulse, and the like, 
and the feetal heart-sounds continue to be normal — labor may be allowed 
to go on for some hours after the rupture of the membranes, so a- to 
give nature a chance of completing the delivery. When this seems 
hopeless the intervention of art is called for. 

Cases Suitable for the Forceps. — The forceps is generally considered to 
be applicable in all degrees of contraction, from the standard measure- 
ment down to about Z\ inches in the conjugate of the brim. There can 
be no doubt that in such cases traction with the forceps often enable- us 
to effect delivery when the natural efforts have proved insufficient, and 
holds out a very fair hope of saving the child. Out of 17 cases in 
which the high forceps operation was resorted to for pelvic deformity, 
reported by Stanesco, in 13 living children were born. If the length 
of the labor and the long-continued compression to which the child has 
been subjected be borne in mind, this result must be considered very 
favorable. 

Objections that have been Raised to the Forceps. — What are the objec- 
tions which have been brought against the operation ? These have been 
principally made by Schroeder and other German writer.-. They are, 
chiefly, the difficulty of passing the Instrument, the risk of injuring i In- 
maternal structures, and the supposition that, as the blades musl seize 
the head by the forehead and occiput, their compressive action will 
diminish its longitudinal and increase its transverse diameter (which ifl 
opposed to the contracted part of the brim), and so enlarge the headjusl 
where it ought to be smallest. There is little doubl that these writers 
much exaggerate the compressive power of the forceps. ( tertainly, with 
those generally used in this country, any disadvantage likely i" accrue 
from this is more than counterbalanced by the traction on the head : and 
the fact that minor degrees of obstruction can be thus overcome \\ nh 



396 LABOR. 

both to the mother and child is abundantly proved by the numberless 
cases in which the forceps has been used. 

Not equally Suitable in all Kinds of Deformity. — It is very likely that 
the forceps does not act equally well in all cases. When the head is loose 
above the brim ; when the contraction is chiefly limited to the antero- 
posterior diameter, and there is abundance of room at the sides of the 
pelvis for the occiput to occupy after version ; and when, as is usual in 
these cases, the anterior fontanelle is depressed and the head lies trans- 
versely across the brim, — it is probable that turning may be the safer 
operation for the mother, and the easier performed. When, on the other 
hand, the head has engaged in the brim and has become more or less 
impacted, it is obvious that version could not be performed without 
pushing it back, which may be neither easy nor safe. In the generally- 
contracted pelvis, in which the head enters in an exaggerated state of 
flexion and lies obliquely, the posterior fontanelle being much depressed, 
the forceps is more suitable. 

Mechanical Advantage of Turning in Certain Cases. — The special 
reasons why version sometimes succeeds when the forceps fails, or why 
it may be elected from the first as a matter of choice, have been by no 
one better pointed out than by Sir James Simpson. Although the ope- 
ration was performed by many of the older obstetricians, its revival in 
modern times and the clear enunciation of its principles can undoubtedly 
be traced to his writings. He points out that the head of the child is 
shaped like a cone, its narrowest portion the base of the cranium (Fig. 
142, b b), measuring, on an average, from -| to f of an inch less than 
the broadest portion (Fig. 142, a a) — viz. the bi-parietal diameter. In 



Fig. 143. 



Fig. 142. 



Section of Foetal Cranium, showing Showing the Greater Breadth of the 

its Conical Form. Bi-parietal Diameter of the Fcetal 

Cranium. (After Simpson.) 

ordinary head presentations the latter part of the head has to pass first ; 
but if the feet are brought down, the narrow apex of the cranial cone is 
brought first into apposition with the contracted brim, and can be more 
easily drawn through than the broader base can be pushed through by 
the uterine contractions. Nor is this the only advantage, for after turn- 
ing the narrower bi-temporal diameter (Fig. 143, b b) — which measures, 
on an average, half an inch less than the bi-parietal (Fig. 143, a a) — is 
brought into contact with the contracted conjugate, while the broader bi- 
parietal lies in the comparatively wide space at the side of the pelvis 



DEFORMITIES OF THE PELVIS. 397 

(Fig. 144). These mechanical considerations are sufficiently obvious, 
and fully explain the success which has often attended the performance 
of the operation. 

Limits of the Operation. — It is generally admitted that it may be pos- 
sible, for the reasons just mentioned, to deliver a living child by turning 

Fig. 144. 




Showing the Greater Space for the Bi-parietal Diameter at the side of the Pelvis in Certain 
Cases of Deformity. (After Simpson.) 

through a pelvis contracted beyond the point which would permit of a 
living child being extracted by the forceps. Many obstetricians believe 
that it is possible to deliver a living child by turning in a pelvis con- 
tracted even to the extent of 2J inches in the conjugate diameter. Barnes 
maintains that, although an unusually compressible head may be drawn 
through a pelvis contracted to 3 inches, the chance of the child being 
born alive under such circumstances must necessarily be small, and that 
from 31 inches to the normal size must be taken as the proper limits of 
the operation. 

It frequently Succeeds when the Forceps has Foiled. — That delivery is 
often possible by turning after the forceps and the natural power- have 
failed, and when no other resource is left but the destruction of the child, 
must, I think, be admitted by all, for the records of obstetrics are full 
of such cases. To take one example only : Dr. Braxton Hicks 1 records 
four cases in which the forceps were tried unsuccessfully, in all of which 
version was used, three of the children being born alive. Here are the 
lives of three children rescued from destruction within a Bhori period in 
the practice of one man; and a fact like this would of itself l>c ample 
justification of the attempt to deliver by turning when the child was 
known to be alive and other means had failed. The possibility that 
craniotomy may still be required is no argument against the operation ; 
for although perforation of the after-coming head is certainly not bo easy 
as perforation of a presenting head, it is not so much more difficult as to 
justify the neglect of an experiment by which it may possibly be alto- 
gether avoided. 

Comparative Estimate of the Two Operations. — The original choice of 
turning is a more difficult question to decide. The most generally 
received opinion in the present day amongst scientific obstetricians is 
that in the simply flattened pelvis, with an antero-posterjor diarat t< 
not less than 2f inches, turning is the preferable operation. In 1 
1 Gmjx Hospital Reports, 1870. 



398 LABOR. 

case of doubt it is desirable thoroughly to anaesthetize the patient and 
make a careful examination with the whole hand in the vagina. If we 
find the sagittal suture lying transversely, one parietal bone on a lower 
line than the other, and if both fontanelles are easily within reach, and 
some space exists at the sides of the pelvis beside the forehead and occi- 
put, then turning is the procedure most likely to succeed, and the descent 
of the head after version can be very materially assisted by strong pres- 
sure applied from above by an assistant, as has been well pointed out by 
Goodell. 1 If, on the other hand, the anterior fontanelle is high up and 
out of reach, the head being distinctly flexed, we have to do with a gen- 
erally-contracted pelvis, and the forceps is the preferable operation. 

Cases in which Craniotomy or the Ccesarean Section is Required. — 
When the contraction is below 3 inches in the conjugate, or when the 
forceps and turning have failed, no resource is left but the destruction of 
the foetus or the Caesarean section. 

The induction of premature labor as a means of avoiding the risks of 
delivery at term, and of possibly saving the life of the child, must now 
be studied. The established rule in this country is, that in all cases of 
pelvic deformity, the existence of which has been ascertained either by 
the experience of former labors or by accurate examination of the pelvis, 
labor should be induced previous to the full period, so that the smaller 
and more compressible head of the premature foetus may pass where 
that of the foetus at term could not. The gain is a double one — partly 
the lessened risk to the mother, and partly the chance of saving the 
child's life. 

Recent Objections to it. — The practice is so thoroughly recognized as a 
conservative and judicious one that it might be hardly necessary to argue 
in its favor, were it not that some eminent authorities have of late years 
tried to show that it is better and safer to the mother to leave the labor to 
come on at term, and that the risk to the child is so great in artificially- 
induced labor as to lead to the conclusion that the operation should be 
altogether abandoned, except, perhaps, in the extreme distortion in which 
the Csesarean section might otherwise be necessary. Prominent amongst 
those who hold these views are Spiegelberg and Litzmann ; and they 
have been supported, in a modified form, by Matthews Duncan. Spie- 
gelberg 2 tries to show, by a collection of cases from various sources, that 
the results of induced labor in contracted pelvis are much more unfavor- 
able than when the cases are left to nature — that in the latter the mor- 
tality of the mothers is 6.6 per cent., and of the children 28.7 per cent., 
whereas in the former the maternal deaths are 15 per cent., and the 
infantile 66.9 per cent. Litzmann 3 arrives at not very dissimilar results 
— namely, 6.9 per cent, of the mothers and 20.3 per cent, of the children 
in contracted pelvis at term, and 14.7 per cent, of the mothers and 55.8 
per cent, of the children in artificially-induced premature labor. 

If these statistics were reliable, inasmuch as they show a very decided 
risk to the mother, there might be great force in the argument that it 
would be better to leave the cases to run the chance of delivery at term. 
It is, however, very questionable whether they can be taken, in them- 

1 Amer. Journ. of Obstet., vol. viii. 2 Arch.f. Gyn., B. i. S. 1. 

3 lb., B. ii. S. 169. 



DEFORMITIES OF THE PELVIS. 399 

selves, as being sufficient to settle the question. The fallacy of deter- 
mining such points by a mass of heterogeneous cases, collected together 
without a careful sifting of their histories, has over and over again been 
pointed out; and it would be easy enough to meet them by an equal 
catalogue of cases in which the maternal mortality is almost nil. The 
results of the practice of many authorities are given in Churchill's work, 
where we find, for example, that out of 46 cases of Merrhnan's not one 
proved fatal. The same fortunate result happened in <52 cases of Rams- 
botham's. His conclusion is that " there is undoubtedly some risk 
incurred by the mother, but not more than by accidental premature 
labor;" and this conclusion as regards the mother is that which has long 
ago been arrived at by the majority of British obstetricians, who un- 
doubtedly have more experience of the operation than those of any other 
nation. With regard to the child, even if the German statistics be taken 
as reliable, they would hardly be accepted as contraindicating the opera- 
tion, inasmuch as it is intended to save the mother from the danger- i >f 
the more serious labor at term, and in many cases to give at Least a 
chance to the child, whose life would otherwise be certainly sacrificed. 
The result, moreover, must depend to a great extent on the method of 
operation adopted, for many of the plans of inducing labor recommended 
are certainly, in themselves, not devoid of danger both to the mother and 
the child. It may, I think, be admitted, as Duncan contends, 1 that the 
operation has been more often performed than is absolutely necessary, 
and that the higher degrees of pelvic contraction are much more uncom- 
mon than has been supposed to be the case. That is a very valid reason 
for insisting on a careful and accurate diagnosis, but not for rejecting an 
operation which has so long been an established and favorite resource. 

Determination of Period for Inducing Labor. — When the induction 
of labor has been determined on, the precise period at which it should 
be resorted to becomes a question for anxious consideration, since the 
longer it is delayed the greater, of course, are the dangers for the child. 
Many tables have been constructed to guide us on this point which arc 
not, on the whole, of so much service as they might appear to be, on 
account of the difficulty of determining with minute accuracy the amounl 
of contraction. The following, however, which is drawn up by Kiwisch, 
may serve for a guide in settling this question : 

[nches. Lines. 



When the sacro 


-pubi 


c diameter 

U 


is '2 and 
'1 '' 
•1 •' 
3 " 


(5 or 7, 

8 ' ; 9, 

10 " 11, 


induce 1 


labor 


at 30th week 
31s1 - 
32d - 
33d - 


u 




'< 


:; •• 


1, 






33d - 


u 




it 


3 - 


2 " 'A, 






34th ■ 


it 




" 


3 - 


4 " 5, 


•• 




36th - 


u 




(i 


:; " 


5 " 0, 






36th " 



In cases of moderate deformity, when labor-pains have been induced, 
the further progress of the case may l>c left to nature; but in more 
marked cases, as in those below 3 inches, it will often be found neces- 
sary to assist delivery by turning or by the forceps, the former being 
l Edin. Med. Journ., July, 1873, p. ■)■'>'■>. 



400 LABOR. 

here specially useful, on account of the extreme pliability of the head 
and the facility with which it may be drawn through the contracted 
brim. By thus combining the two operations it may be quite possible 
to secure the birth of a living child even in pelves very considerably 
deformed. 

Production of Abortion in Extreme Deformity. — When the contraction 
is so great as to necessitate the induction of the labor before the sixth 
month — or, in other words, before the child has reached a viable age — 
it would be preferable to resort to a very early production of abortion. 
The operation is then indicated, not for the sake of the child, but to 
save the mother from the deadly risk to which she would otherwise be 
subjected. As in these cases the mother alone is concerned, the opera- 
tion should be performed as soon as we have positively determined the 
existence of pregnancy. No object can be gained by waiting until the 
development of the child is advanced to any extent, and the less the 
foetus is developed the less will be the pain and risks the mother has 
to undergo. There is no amount of deformity, however great, in which 
Ave could not succeed in bringing on miscarriage by some of the numer- 
ous means at our disposal ; and, in spite of Dr. Radford's objections, 
who maintains that the obstetrician is not justified in sacrificing the life 
of a human being more than once when the mother knows that she can- 
not give birth to a viable child, there are few practitioners who would 
not deem it their duty to spare the mother the terrible dangers of the 
Csesarean section. 



CHAPTER XIII. 

HEMOEKHAGE BEFORE DELIVERY; PLACENTA PREVIA. 

The hemorrhages which are the result of an abnormal situation of 
the placenta, partially or entirely, over the internal os uteri have formed 
a most fruitful theme for discussion. The explanation of the abnormal 
placental site, the sources of the blood, and the causes of its escape, the 
means adopted by nature for its arrest, and the proper treatment, have, 
each and all of them, been the subject of endless controversies, which 
are not yet by any means settled. It must be admitted, too, that the 
extreme importance of the subject amply justifies the attention which 
has been paid to it, for there is no obstetric complication more apt to 
produce sudden and alarming effects, and none requiring more prompt 
and scientific treatment. 

Definition. — By placenta propria we mean the insertion of the placenta 
at the lower segment of the uterine cavity, so that a portion of it is situ- 
ated, wholly or partially, over the internal os uteri. In the former case 
there is complete or central placental presentation, in the latter an incom- 
plete or marginal presentation. 

Causes. — The causes of this abnormal placental site are not fully 



HEMORRHAGE BEFORE DELIVERY. 401 

understood. It was supposed by Tyler Smith to depend on the ovule 
not having been impregnated until it had reached the lower part of the 
uterine cavity. Cazeaux suggests that the uterine mucous membrane 
is less swollen and turgid than when impregnation occurs at the more 
ordinary place, and that, therefore, it offers less obstruction to the de- 
scent of the ovule to the lower part of the uterine cavity. An abnormal 
size or unusual shape of the uterine cavity may also favor the descent 
of the impregnated ovule; the former probably explains the fact that 
placenta prsevia more generally occurs in women who have already 
borne children. Mtiller believes that it results from uterine contrac- 
tions occurring, shortly after conception, which force the ovum down to 
the lower part of the uterine cavity. These are merely interesting specu- 
lations, having no practical value, the fact being undoubted that in a not 
inconsiderable number of cases — estimated by Johnson and Sinclair as 1 
out of 573 — the placenta is grafted partially or entirely over the uterine 
orifice. 

Hidory. — Placenta prsevia was not unknown to the older writers, 
who believed that the placenta had originally been situated at the 
fundus, from which it had accidentally fallen to the lower part of the 
uterus. Portal, Levret, Roederer, and especially our own countryman 
Rigby, were among those whose observations tended to improve the 
state of obstetrical knowledge as to its real nature. To Rigby we owe 
the term "unavoidable hemorrhage" as a synonym for placenta prsevia, 
and as distinguishing hemorrhage from this source from that resulting 
from separation of the placenta at its more usual position, termed by 
him, in contradistinction, "accidental hemorrhage" These names, 
adopted by most writers on the subject, are obviously misleading, as 
they assume an essential distinction in the etiology of the hemorrhage 
in the two classes of cases which is not always warranted. 

It is of the utmost importance to a right understanding of the nature 
and treatment of placenta prsevia that we should fully understand the 
source; of the hemorrhage and the manner of its production ; but we 
shall be able to discuss this subject better after a description of the 
symptoms. 

Symptoms. — Although the placenta must occupy its unusual site from 
the earliest period of its formation, it rarely gives rise to appreciable 
symptoms before the last three months of utero-gestation. It is far from 
unlikely, however, that such an abnormal situation of the placenta may 
produce abortion in the earlier months, the site of its attachment pass- 
ing unobserved. 

Sudden Flow of Blood. — The earliest symptom which causes suspicion 
is the sudden occurrence of hemorrhage without any appreciable cause. 
The amount of blood lost varies considerably. In some cases the first 
hemorrhage is comparatively slight, and i- soon spontaneous!)' arrested ; 
but if the case be left to itself, the How after a lapse of time— it may be 
a few days or it may be weeks — again commences in the same unex- 
pected way, and each successive hemorrhage is more profuse. The 
losses show themselves at different periods. They rarely begin before 
the end of the sixth month, more often nearer the full period, and some- 
times not until labor has actually commenced. The hemorrhage very 

26 



402 LABOR. 

often coincides with what would have been a menstrual period, doubt- 
less on account of the physiological congestion of the uterine organs 
then present. Should the first loss not show itself until at or near the 
full time, it may be tremendous, and a few moments may suffice to 
place the patient's life in jeopardy. Indeed, it may be safely accepted 
as an axiom that once hemorrhage has occurred the patient is never 
safe, for excessive losses may occur at any moment without warning 
and when assistance is not at hand. It often happens that premature 
labor comes on after one or more hemorrhages. 

In any case of placenta prsevia when labor has commenced, whether 
premature or at the full time, the hemorrhage may become excessive, 
and with each pain fresh portions of placenta may be detached and 
fresh vessels torn and left open. Under these circumstances the blood 
often escapes in greater quantity with each successive pain, and dimin- 
ishes in the interval. This has long been looked upon as a diagnostic 
mark by which we can distinguish between the so-called " unavoidable" 
and " accidental " hemorrhage ; in the latter the flow being arrested 
during the pains. The distinction, however, is altogether fallacious. 
The tendency of uterine contraction in placenta prsevia, as in all other 
forms of uterine hemorrhage, is to constrict the vessels from which the 
blood escapes, and so to lessen the Aoav. The apparently increased flow 
during the pains depends on the pains forcing out blood which has 
already escaped from the vessels. In one way, up to a certain point, 
the pains do favor hemorrhage by detaching fresh portions of placenta ; 
but the actual loss takes place chiefly during the intervals, and not 
during the continuance of contraction. 

Results of Vaginal Examination. — On vaginal examination, if the os 
be sufficiently open to admit the finger — which it generally is, on ac- 
count of the relaxation produced by the loss of blood — we shall almost 
always be able to feel some portion of presenting placenta. If it be a 
central implantation, we shall find the upper aperture of the cervix 
entirely covered by a thick, boggy mass, which is to be distinguished 
from a coagulum by its consistence and by its not breaking down under 
the pressure of the finger. Through the placental mass we may feel the 
presenting part of the foetus, but not as distinctly as when there is no 
intervening substance. In partial placental presentations the bag of 
membranes, and above it the head or other presentation, will be found 
to occupy a part of the circle of the os, the rest being covered by the 
edge of the placenta. In marginal presentations we may only be able to 
make out the thickened edge of the after-birth projecting at the rim of 
the os. If the cervix be high and the gestation not advanced to term, 
these points may not be easy to make out on account of the difficulty of 
reaching the cervix ; and, as accurate diagnosis is of the utmost import- 
ance, it is proper to introduce two fingers, or even the whole hand, so as 
thoroughly to explore the condition of the parts. The lower portion of 
the uterine ovoid may be observed to be more than usually thick and 
fleshy ; and Gendrin has pointed out that ballottement cannot be made 
out. The accuracy of our diagnosis may be confirmed, in doubtful 
cases, by finding that the placental bruit is heard over the lower part of 
the uterine tumor. 



HEMORRHAGE BEFORE DELIVERY. 403 

Dr. Wallace 1 has suggested that vaginal auscultation may be service- 
able in diagnosis, and states that by means of a curved wooden stetho- 
scope the placental bruit may be heard with startling distinctness. This 
is, however, a manoeuvre that can hardly be geiierallv carried out in 
actual practice. 

The Source of Hemorrhage. — It is now generally admitted by author- 
ities that the immediate source of the hemorrhage is the lacerated utero- 
placental vessels. Only a few years ago Sir James Simpson advocated 
with his usual energy the theory, sustained by his predecessor, Dr. 
Hamilton, that the chief if not the only source of hemorrhage was the 
detached portion of the placenta itself. He argued that the blood flowed 
from the portion of the placenta which was still adherent into that which 
was separated, and escaped from the surface of the latter ; and on this 
supposition he based his practice of entirely separating the placenta. 
having observed that in many cases in which the after-birth had been 
expelled before the child the hemorrhage had ceased. The fact of the 
cessation of the hemorrhage, when this occurs, is not doubted, but Simp- 
son's explanation is contested by most modern writers, prominent among 
whom is Barnes, who has devoted much study to the elucidation of the 
subject. He points out that the stoppage of the hemorrhage is not due 
to the separation of the placenta, but to the preceding or accompanying 
contraction of the uterus, which seals up the bleeding vessels, just as ir 
does in other forms of hemorrhage. The site of the loss was actually 
demonstrated by the late Dr. Mackenzie in a series of experiments in 
which he partially detached the placenta in pregnant bitches, and found 
that the blood flowed from the walls of the uterus, and not from the 
detached surface of the placenta. The arrangement of the large venous 
sinuses, opening as they do on the uterine mucous membrane, favors the 
escape of blood when they are torn across; and it is from them, possibly 
to some extent also from the uterine arteries, that the blood come-, just 
as in post-partum hemorrhage, when the whole instead of a pari <>f* the 
placental site is bared. 

Causes of Hemorrhage. — Various explanations have been given of the 
oauses of the hemorrhage. It was long supposed to depend mi the 
gradual expansion of the cervix during the latter months of pregnancy, 
which separated the abnormally placed placenta. It ha- been seen, 
however, that this shortening of the cervix is apparent only, and that 
the cervical canal is not taken up into the uterine cavity during gesta- 
tion, or, at all events, only during the last week or .-<>. This, therefore, 
cannot be admitted as an explanation of placental separation. Jacque- 
mier proposed another theory, which has been adopted by Cazeaux. 
He maintains that during the first Bis months of iitero-gestation the 
superior portion of the uterus is more especially developed, as Bhown by 
the pyriform shape of the fundus during the time, and that, as the pla- 
centa' is usually attached in that situation, and then attains it- maximum 
of development, its relations to its attachments are undisturbed. Dur- 
ing the last three months of pregnancy, on the contrary, the lowi i 
ment of the uterus develops more than the upper, while the placenta 
remains nearly stationary in size, the inevitable result hem- a loss oi 
1 Edin. Med. Journ.. Nov., 1872. 



404 LABOR. 

proportion between the cervix and the placenta, and the detachment of 
the latter. There are various objections which can be brought against 
this theory, the most important being that there is no evidence at all to 
show that the lower segment of the uterus does expand more in propor- 
tion than the upper during the latter months of pregnancy. Barnes's 
theory is based on the supposition that the loss of relation between the 
uterus and placenta is caused by excess of growth on the part of the 
placenta itself over that of the cervix, which is not adapted for its 
attachment. The placenta, on this hypothesis, grows away from the 
site of its attachment, and hemorrhage results. It will be observed that 
neither this theory nor that propounded by Jacquemier is readily recon- 
cilable with the fact that hemorrhage frequently does not begin until 
labor has commenced at term. Inasmuch as the loss of relation between 
the placenta and its attachments, which they both presuppose, must exist 
in every case of placenta prsevia, hemorrhage should always occur dur- 
ing some part of the last three months of pregnancy. Matthews Dun- 
can l has recently investigated the whole subject at length, and maintains 
that the hemorrhages are accidental, not unavoidable, being due to 
causes precisely similar to those which give rise to the occasional hemor- 
rhages when the placenta is normally placed. The abnormal situation 
of the placenta of course renders these causes more apt to operate ; but 
in their action he believes them to be precisely similar to those of acci- 
dental hemorrhage, properly so called. Separation of the placenta from 
expansion of the cervix he believes to be the cause of hemorrhage after 
labor has begun, and then it may strictly be called unavoidable ; but 
hemorrhage is comparatively seldom so produced during the continuance 
of pregnancy. " There are," says Duncan, " four ways in which this 
kind of hemorrhage may occur : 

" 1. By the rupture of a utero-placental vessel at or about the inter- 
nal os uteri. 

" 2. By the rupture of a marginal utero-placental sinus within the 
area of spontaneous premature detachment when the placenta is inserted 
not centrally or covering the internal os, but with a margin at or near 
the internal os. 

" 3. By partial separation of the placenta from accidental causes, such 
as a jerk or fall. 

" 4. By a partial separation of the placenta the consequence of uterine 
pains, producing a small amount of dilatation of the internal os. Such 
cases may be otherwise described as instances of miscarriage commen- 
cing, but arrested at a very early stage." 

I see no reason to doubt the possibility of hemorrhage being due in 
many cases to the first three causes, and in its production it would 
strictly resemble accidental hemorrhage. The fourth heading refers the 
hemorrhage to partial separation in consequence of commencing dilata- 
tion of the cervix, but it explains the dilatation by the supposition of 
commencing miscarriage. This latter hypothesis seems to be as needless 
as those which presuppose a want of relation between the placenta and 
its attachments. We know that, quite independently of commencing 
miscarriage, uterine contractions are constantly occurring during the 

1 Edln. Med. Journ. 



HEMORRHAGE BEFORE DELIVERY. 405 

continuance of pregnancy. There is no reason to suppose that these 
contractions do not affect the cervical as well as the fundal portions of 
the uterus ; and in cases in which the placenta is situated partially or 
entirely over the os, one or more stronger contractions than usual may 
at any moment produce laceration of the placental attachments in that 
neighborhood. 

Pathological Changes in the Placenta. — A careful examination of the 
placenta may show pathological changes at the site of separation, such as 
have been described by Gendrin, Simpson, and other writers. They 
probably consist of thromboses in the placental cotyledons and effused 
blood-clots, variously altered and decolorized according to the lapse of 
time since separation took place. Changes occur in the portion of the 
placenta overlying the os uteri whether separation has occurred or not. 
There may be atrophy of the placental structure in this situation, as 
well as changes of form, such as complete or partial separation into two 
lobes, the junction of which overlies the os uteri. 1 

Natural Termination when the Placenta Presents. — The history of 
delivery, if left to nature, is specially worthy of study, as guiding to 
proper rules of treatment. It sometimes happens, when the pains arc 
very strong and the delivery rapid, that labor is completed without any 
hemorrhage of consequence. "Although," says Cazeaux, "hemorrhage 
is usually considered to be inevitable under such circumstances, ye1 it 
may not appear even during the labor, and the dilatation of the os uteri 
may be effected without the loss of a drop of blood." Again, Simpson 
conclusively showed that when the placenta was expelled before the 
birth of the child all hemorrhage ceased. 

Barnes's theory of placenta prcevia, which has been pretty generally 
adopted, explains satisfactorily both these classes of cases. He describes the 
uterine cavity as divisible into three zones or regions. When the placenta 
is situated in the upper or middle of these zones, no separation or hem- 
orrhage need occur during labor. When, however, it is situated partially 
or entirely in the lower or cervical zone, the expansion of the cervix 
during labor must produce more or less separation, and consequenl loss 
of blood. As soon as the previous portion of the placenta Is sufficiently 
separated, provided contraction of the uterine tissue be present to seal 
up the mouths of the vessels, hemorrhage no longer takes place The 
placenta may not be entirely detached, but no further hemorrhage occurs, 
in consequence of the remaining portion being engrailed on the uterus 
beyond the region of unsafe attachment. In the former, then, of these 
classes of cases the absence of hemorrhage is explained on this theory by 
the pains being sufficiently rapid and strong to complete the separation 
of the placental attachment from the lower cervical /one before flooding 
had taken place; in the latter, it ceases, not necessarily because the entire 
placenta is expelled, but because of its detachmenl from the area of dan- 
gerous implantation. 

The amount of cervical expansion required for this purpose varies in 
different cases. Dr. Duncan 2 estimates the limn of the pontaneous 
detaching area to be a circle of 4J inches diameter, and thai after the 
cervix has expanded to that extent no further separation or hemorrhage 

1 Simelius, Arch. (fen. de Med., vol. ii., 1861. ' Oh fd *V. 



406 LABOR. 

takes place. To admit of the passage of a full-sized head, Barnes esti- 
mates that expansion to about a circle of 6 inches diameter is necessary ; 
on the other hand, he has sometimes observed " that the hemorrhage has 
completely stopped when the os uteri opened to the size of the rim of a 
wine-glass, or even less." 

It will be seen, then, that in this, as in every other form of puerperal 
hemorrhage, the tendency of uterine contraction is to check the hemor- 
rhage, and that, provided the pains are sufficiently energetic, Nature may 
be capable of stopping the flooding without artificial aid. It is but 
rarely, however, that she can be trusted for the purpose • and we shall 
presently see that these theoretical views have an important practical 
bearing on the subject of treatment. 

Prognosis. — The prognosis to both the mother and child is certainly 
grave in all cases of placenta praevia. Read, in his treatise on placenta 
praevia, estimates the maternal mortality, from the statistics of a large 
number of cases, as 1 in A\ cases, and Churchill as 1 in 3. This is 
unquestionably too high an estimate, and based on statistics the accuracy 
of which cannot be relied on. The mortality will, of course, greatly 
depend on the treatment adopted. Doubtless, if cases were left to nature 
the result would be quite as unfavorable as Read supposes. But if 
properly managed much more successful results may be safely anticipated. 
Out of 64 cases recorded by Barnes, the deaths were 6, or 1 in lOf . Under 
any circumstances the risks to the mother are very great. Churchill 
estimates that more than half the children are lost. The reasons for the 
great danger to the child are very obvious, subjected as it is to the risk 
of asphyxia from the loss of the maternal blood, and from its respira- 
tion being carried on during labor by a placenta which is only partially 
attached ; many children also perish from prematurity or from mal- 
presentation. 

Treatment. — Whenever, in the latter months of pregnancy, a sudden 
hemorrhage occurs, the possibility of placenta praevia will naturally sug- 
gest itself, and by a careful vaginal examination — which under such 
circumstances should always be insisted on — the existence of this com- 
plication will generally be readily ascertained. It is seldom that the os 
is not sufficiently dilated to enable us to satisfy ourselves whether the 
placenta is presenting. 

Is it Justifiable to Allow the Pregnancy to Continue f — The first ques- 
tion that will arise is, Are we justified in temporizing, using means to 
check the hemorrhage, and allowing the pregnancy to continue ? This 
is the course which has generally been recommended in works on mid- 
wifery. We are told to place the patient on a hard mattress, not to heat 
or overburden her with clothes, to keep her absolutely at rest, to have 
the room cooled and well aired, to apply cold cloths to the vulva and 
lower part of the abdomen, to administer cold and acidulated drinks in 
abundance, and to prescribe acetate of lead and opium, or gallic acid, on 
account of their supposed haemostatic effect. Of late years the judicious- 
ness of these recommendations has been strongly contested. Not long 
ago an interesting discussion took place at the Obstetrical Society of 
London l on a paper in which Dr. Greenhalgh advised the immediate 

1 Obst. Trans., vol. vi. p. 188. 



HEMORRHAGE BEFORE DELIVERY. 407 

induction of labor in all oases of placenta prsevia. Xo less than six 
metropolitan teachers of midwifery took part in it, and, although they 
differed in details, they all agreed as to the unadvisability of allowing 
pregnancy to progress when the existence of placenta prsevia had been 
distinctly ascertained. The reasons for this course are obvious and 
unanswerable. The labor, indeed, very often comes on of its own accord, 
but should it not do so the patient's life must be considered to be always 
in jeopardy until the case is terminated, for no one can be sure that most 
dangerous, or even fatal, flooding may not at any moment come on ; and 
the nearer to term the patient is, the greater the risk to which she is 
subjected. Xor is the safety of the child likely to be increased by delay. 
Provided it has arrived at a viable age, the chances of its being born 
alive may be said to be greater if pregnancy be terminated at once than 
if repeated floodings occur. I think, therefore, that it may be safely 
laid down as an axiom that no attempt should be made to prevent the 
termination of pregnancy, but that our treatment should rather contem- 
plate its conclusion as soon as possible. An exception may, however, be 
made to this rule when the hemorrhage occurs for the first time before 
the seventh month of utero-gestation. The chances of the child sur- 
viving would then be very small, and if the hemorrhage be not alarm- 
ing, as at that early period is likely to be the case, the measure- indicated 
above may be employed in the hope of carrying on the pregnancy until 
there is a prospect of the patient being delivered of a living child, lint 
little benefit is likely to accrue from astringent drugs. Perfect rest in 
bed is more likely to be beneficial than anything else, and astringent 
vaginal pessaries of matico or perchloride of iron might be used with 
advantage as local haemostatics. 

Various Jlethods of Treatment. — When the period of pregnancy or 
the urgency of the case determines us to forego any attempt at temporiz- 
ing, there are various plans of treatment to be considered. These are, 
chiefly: 1. Puncture of the membranes ; 2. Plugging of the vagina ; •">. 
Turning; 4. Partial or complete xcpa rat 'am of the placenta. It will be 
well to consider in detail the relative advantages of, and indications for, 
each of these. It is seldom, however, that we can trusl t<> any one per 
ne; in most cases two or more are required to be used in combination. 

1. Puncture of the membrane* is recommended by Barnes as the first 
measure to be adopted in all cases of placenta prsevia sufficient t<> cause 
anxiety. "It is," he says, "the most generally efficacious remedy, and 
it can always be applied." The primary object gained is the increaseof 
uterine contraction by the evacuation of tin- liquor anniii. Although 
the first effect of this may be to increase the flow of blood by further 
separation of the placenta, the flooding can generally !>«• commanded by 
plugging until the os is sufficiently dilated to permit the passage of the 
child. As a rule, there is no great difficulty in effecting the puncture, 
especially if the placental presentation be only partial. A quill orother 
suitable contrivance, guided by the examining finger, i- passed through 
the cervix and pushed through the membranes, [n complete placenta 
prsevia it may not be so easy to effect the evacuation of the liquor amnii; 
and, although many authorities advise the penetration of the substance 
of the placenta itself, I am inclined to think that it would l»" better t«> 



408 LABOR. 

abandon the attempt in such cases and trust to other methods of treat- 
ment. 

The objections which have been raised to puncture of the membranes 
are chiefly that it interferes with the gradual dilatation of the os and 
renders the operation of turning much more difficult. The os is not, 
however, so regularly dilated by the bag of membranes in cases of pla- 
centa prsevia as it is in ordinary labors. Moreover, as the cervical tis- 
sues are generally relaxed by the hemorrhage, the dilatation is easily 
effected. Should we desire to dilate the os preparatory to turning, we 
can readily do so by means of Barnes's bags, which act at the same time 
as an efficient plug. The objections, therefore, are not so weighty as they 
might have been before these artificial dilators were used. I am inclined 
for these reasons to agree with the recommendation that puncture of the 
membranes should be resorted to in all cases of placenta prsevia. 

2. Plugging of the vagina — or, still better, of the cavity of the cervix 
itself — is especially serviceable in cases in which the os is not sufficiently 
dilated to admit of turning or of separation of the placenta, and in 
which the hemorrhage still continues after the evacuation of the liquor 
amnii. By means of this contrivance the escape of blood is effectually 
controlled. 

The best way of plugging is to introduce a sponge tent of sufficient 
size into the cervical canal, and to keep it in situ by a vaginal plug ; the 
best material for the latter and the method of introduction are described 
under the head of Abortion. The sponge tent not only controls the 
hemorrhage more effectually than any other means, but is at the same 
time effecting dilatation of the cervix. It cannot be left in many hours, 
on account of the irritation produced and of the fetor from accumulating 
vaginal discharges. As long as it is in position we should carefully 
examine, from time to time, to see that no blood is oozing past it. If 
preferred, a Barnes's bag may be used for the same purpose. 

While the plug is in situ other modes of exciting uterine action may 
be very advantageously employed, such as a firm abdominal bandage, 
occasional friction over the uterus, and repeated doses of ergot. The last 
is specially recommended by Dr. Greenhalgh, who used at the same time 
a plug formed of an oblong india-rubber ball inflated with air and 
covered with spongio-piline. 

On the removal of the plug we may find that considerable dilatation 
has taken place, perhaps to a sufficient extent to admit of labor being 
safely concluded by the natural efforts. In that case we shall find that, 
although the pains continue, no fresh hemorrhage occurs. Should it do 
so, it will be necessary to adopt further measures. 

3. Turning has long been considered the remedy par excellence in pla- 
centa prsevia ; and it is of unquestionable value in suitable cases. Much 
harm, however, has been done when it has been practised before the os 
was sufficiently dilated to admit of the passage of the hand, or when the 
patient was so exhausted by previous hemorrhage as to be unable to bear 
the shock of the operation. The records of many fatal cases in the 
practice of those who taught, as did the large majority of the older 
writers, that turning at all risks was essential conclusively prove this 
assertion. 



HEMORRHAGE BEFORE DELIVERY. 409 

It is most likely to prove serviceable when, either at first or after the 
use of the tampon, the os is sufficiently dilated to admit the hand, and 
when the strength of the patient is not much enfeebled. If she have a 
small, feeble, and thready pulse, it is certainly inapplicable, unless all 
other methods of arresting the hemorrhage have failed. And even then 
it would be well to attempt to rally the patient from her exhausted state 
by stimulants, etc. before the operation is commenced. 

Provided the placental presentation be partial, the operation can be 
performed without difficulty in the usual way. In central implantation 
the passage of the hand may give rise to some difficulty. Dr. Rigby 
recommends that it should be pushed through the substance of the pla- 
centa until it reaches the uterine cavity. It is hardly possible to conceive 
how this could be done without completely detaching the placenta, and 
still less to understand how the foetus could be dragged through the 
aperture thus made. It will be far better to pass the hand by the border 
of the placenta, separating it as we do so; and, if we can ascertain to 
which side of the cervix it is least attached, that should be chosen for 
the purpose. In all cases in which it is possible turning by the bi-polar 
method should be preferred. In cases of placenta prsevia especially it 
offers many advantages. The operation can be soon performed, complete 
dilatation of the os is not so necessary, and it involves less bruising 
of the cervix, which is likely to be specially dangerous. When once a 
foot has been brought within the os, the delivery need not be hurried. 
The foot forms a plug which effectually prevents all further loss, and we 
may then safely wait until we can excite uterine contraction and termi- 
nate the labor with safety. Fortunately, the relaxation of the uterus 
which is so often present facilitates this manner of performing version, 
and it can generally be successfully accomplished. Should the case lu- 
one which is otherwise suitable for turning, and the requisite amount of 
dilatation of the cervix not be present, the latter can generally be 
effected in the space of an hour or more (while at the same time a 
further loss of blood is effectually prevented) by the use of Barnes's bass, 

4. Entire separation of the placenta was originally recommended by 
Simpson in his well-known paper on the subject. The reasons which 
induced him to recommend it have already been stated. It is a mistake 
to suppose, however, as is so often done, that he intended t«> recommend 
it in all cases alike. This supposition he was always careful t<« deny. 
lie advised it especially — 

1. When the child is dead. 

2. When the child is not yet viable. 

3. When the hemorrhage is great and the os uteri is doI y.t sufficiently 
dilated for safe turning. This was the state in 1 1 out of :i , .i eases (La . 

4. When the pelvic passages are too small for safe and easy turning. 

5. When the mother is too exhausted to bear turning. 

6. When the evacuation of the liquor amnii fails. 

7. When the uterus is too firmly contracted for turning. 

These are very much the cases in which all modern accoucheurs would 
exclude the operation of turning ; and it was especially when thai was 
unsuitable that Simpson advised extraction of the placenta. A- his 

1 Selected Obst. Workup. 



410 LABOR. 

theory of the source of hemorrhage is now almost universally disbelieved, 
so has the practice based on it fallen into disuse, and it need not be dis- 
cussed at length. It is very doubtful whether the complete separation 
and extraction of the placenta was a feasible operation ; unquestionably, 
it can be by no means so easy as Simpson's writings would lead us to 
suppose. The introduction of the hand far enough to remove the pla- 
centa in an exhausted patient would probably cause as much shock as 
the operation of turning itself; and another very formidable objection 
to the procedure is the almost certain death of the child if any time 
elapse between the separation of the placenta and the completion of 
delivery. The modification of this method so strongly advocated by 
Barnes is certainly much easier of application, and would appear to 
answer every purpose that Simpson's operation effected. It is impossible 
to describe it better than in Barnes's own words : 1 

" The operation is this : Pass one or two fingers as far as they will go 
through the os uteri, the hand being passed into the vagina if necessary ; 
feeling the placenta, insinuate the finger between it and the uterine wail ; 
sweep the finger round in a circle so as to separate the placenta as far as 
the finger can reach : if you feel the edge of the placenta where the 
membranes begin, tear open the membranes carefully, especially if these 
have not been previously ruptured ; ascertain, if you can, what is the 
presentation of the child before withdrawing your hand. Commonly, 
some amount of retraction of the cervix takes place after the operation, 
and often the hemorrhage ceases." 

It will be seen, from what has been said, that no one rule of practice 
can be definitely laid clown for all cases of placenta prsevia. Our treat- 
ment in each individual case must be guided by the particular conditions 
that are present ; and if only we bear in mind the natural history of the 
hemorrhage, we may confidently look to a favorable termination. 

Summary of Rules for Treatment. — It may be useful, in conclusion, to 
recapitulate the rules which have been laid down for treatment in the 
form of a series of propositions : 

I. Before the child has reached a viable age temporize, provided the 
hemorrhage be not excessive, until pregnancy has advanced sufficiently 
to afford a reasonable hope of saving the child. For this purpose the 
chief indication is absolute rest in bed, to which other accessory means 
of preventing hemorrhage, such as cold, astringent pessaries, etc., may be 
added. 

II. In hemorrhage occurring after the seventh month of utero-gesta- 
tion no attempt should be made to prolong the pregnancy. 

III. In all cases in which it can be easily effected the membranes 
should be ruptured. By this means uterine contractions are favored and 
the bleeding vessels compressed. 

IV. If the hemorrhage be stopped, the case may be left to nature. 
If flooding continue, and the os be not sufficiently dilated to admit of 
the labor being readily terminated by turning, the os and the vagina 
should be carefully plugged, while uterine contractions are promoted by 
abdominal 'bandages, uterine compression, and ergot. The plug must 
not be left in beyond a few hours. 

1 Obstet. Operations, 2d ed., p. 417. 



HEMORRHAGE BEFORE DELIVERY. 411 

V. If, on removal of the plug, the os be sufficiently expanded and 
the general condition of the patient be good, the labor may be terminated 
by turning, the bi-polar method being used if possible. If the os be not 
open enough, it may be advantageously dilated by a Barnes's bag, which 
also acts as a plug. 

VI. Instead of, or before resorting to, turning the placenta mav be 
separated around the site of its attachment to the cervix. This practice 
is specially to be preferred when the patient is much exhausted and in a 
condition unfavorable for bearing the shock of turning. 

\_Dr. J. Braxton Hicks' bi-manual method of turning* as tested in 
Berlin by Drs. Hofmeier, Behm, and Lomer, promises much better 
results than any other method of treatment in cases of placenta prsevia. 
According to Dr. Lomer's report in the Am. Journ. of Obstetrics for 
December, 1884, Dr. Hofmeier operated upon 37 cases, and saved •">'> 
women and 14 children; Dr. Behm, upon 40 cases, all saved, but lost 
31 children; and he himself, with eight other assistants, upon 101 cases, 
saving 94, with 50 children. This gives 8 deaths of women and 105 
of children in 178 cases, or a mortality of 4^- per cent, of the former 
and 60 per cent, of the latter. Dr. Lomer's direction- are as follows : 
" Turn by the bi-manual method as soon as possible; pull down the leg, 
and tampon with it and with the breech of the child the ruptured \ 
of the placenta. Do not extract the child then: let it come by itself, or 
at least only assist its natural expulsion by gentle and rare tractions. I )<> 
away with the plug as much as possible; it is a dangerous thing, tor it 
favors infection and valuable time is lost with its application. Do not 
wait in order to perform turning until the cervix and the os arc suf- 
ficiently dilated to allow the hand to pass. Turn as soon a- you can 
pa— one or two fingers through the cervix. It is unnecessary to force 
your fingers through the cervix for this. Introduce the whole hand into 
the vagina, pass one or two fingers through the cervix, rupture the mem- 
branes, and turn by Braxton Hicks' bi-manual method." . ... "If the 
placenta is in your way, try to rupture the membranes at its margin ; bui 
if this is not feasible, do not lose time: perforate the placenta with your 
finger; get hold of a leg as soon as possible, and bring it down. 1 ' — Ed.] 



CHAPTER XIV 



HEMORRHAGE FROM SEPARATION OF A NORMALLY-SITUATED 

PLACENTA. 

Definition. — This is the form of hemorrhage which is generally de- 
scribed in obstetric works as " accidental" in contradistinction i<> ih< 
"unavoidable" hemorrhage of placenta praevia. In discussing the latter 
we have seen that the term "accidental" is one thai is apt t<> mislead) 

[ l Lancet, July, 1860; Obstetrical TranaaetUm, vol. v. p. -J-J-J.J 



412 LABOR. 

and that the causation of the hemorrhage in placenta prsevia is, in some 
cases at least, closely allied to that of the variety of hemorrhage we are 
now considering. 

When, from any cause, separation of a normally-situated placenta 
occurs before delivery, more or less blood is necessarily effused from 
the ruptured utero-placental vessels, and the subsequent course of the 
case may be twofold : 1 . The blood, or at least some part of it, may 
find its way between the membranes and the decidua, and escape from 
the os uteri. This constitutes the typical " accidental " hemorrhage of 
authors. 2. The blood may fail to find a passage externally, and may 
collect internally, giving rise to very serious symptoms, and even proving 
fatal, before the true nature of the case is recognized. Cases of this 
kind are by no means so rare as the small amount of attention paid to 
them by authors might lead us to suppose ; and from the obscurity of 
the symptoms and difficulty of diagnosis they merit special study. Dr. 
Goodell 1 has collected together no less than 106 instances in which this 
complication occurred. 

Causes and Pathology. — The causes of placental separation may be 
very various. In a large number of cases it has followed an accident 
or exertion (such as slipping down stairs, stretching, lifting heavy weights, 
and the like) which has probably had the effect of lacerating some of 
the placental attachments. At other times it has occurred without such 
appreciable cause, and then it has been referred to some change in the 
uterus, such as a more than usually strong contraction producing sepa- 
ration, or some accidental determination of blood causing a slight ex- 
travasation between the placenta and the uterine wall, the irritation of 
which leads to contraction and further detachment. Causes such as 
these, which are of frequent occurrence, will not produce detachment 
except in women otherwise predisposed to it. It generally is met with 
in women who have borne many children, more especially in those of 
weakly constitution and impaired health, and rarely in primiparse. Cer- 
tain constitutional states probably predispose to it, such as albuminuria 
or exaggerated anaemia, and, still more so, degenerations and diseases of 
the placenta itself. 

This form of hemorrhage rarely occurs to an alarming extent until 
the latter months of pregnancy, often not until labor has commenced. 
The great size of the placental vessels in advanced pregnancy affords a 
reasonable explanation of this fact. 

Symptoms and Diagnosis. — If, after separation of a portion of the 
placenta, the blood finds its way between the membranes and the decidua, 
its escape per vaginam, even although in small amount, at once attracts 
attention and reveals the nature of the accident. It is otherwise when 
we have to do with a case of concealed hemorrhage, the diagnosis of 
which is often a matter of difficulty. Then the blood probably at first 
collects between the uterus and the placenta. Sometimes marginal sepa- 
ration does not occur, and large blood-clots are formed in this situation 
and retained there. More often the margin of the placenta separates 
and the blood collects between the membranes and the uterine wall, 
either toward the cervix, where the presenting part of the child may 

1 Amer. Journ. of Obst., vol. ii. 



HEMORRHAGE BEFORE DELIVERY. 413 

prevent its escape, or near the fundus. In the latter ease especially the 
coagula are apt to cause very painful stretching and distension of the 
uterus. The blood may also find its way into the amniotic cavity, lmt 
more frequently it does not do so — probably, as Goodell has pointed out, 
because, " should the os uteri be closed, the membranes, however deli- 
cate, cannot, other things being equal, rupture any sooner from the ute- 
rine walls, for the sum of the resistance of the enclosed liquor amnii, 
being equally distributed, exactly counterbalances the sum of the pres- 
sure exerted by the effusion." This point is of some practical import- 
ance, because, after rupture of the membranes, the liquor amnii i- fre- 
quently found untinged with blood; and this might lead us to suppose 
ourselves mistaken in our diagnosis if this fact were not borne in mind. 

Symptoms of Concealed Accidental Hemorrhage. — The most promi- 
nent symptoms in concealed internal hemorrhage are extreme collapse 
and exhaustion, for which no adequate cause can be assigned. These 
differ from those of ordinary syncope, with which they might be con- 
founded, chiefly in their persistence and severity, and in the present 
the symptoms attending severe loss of blood, such as coldness and pallor 
of the surface, great restlessness and anxiety, rapid and sighing respira- 
tion, yawning, feeble, quick, and compressible pulse. When there is 
severe internal, with slight external, hemorrhage, we may be led to a 
proper diagnosis by observing that the constitutional symptoms are much 
more severe than the amount of external hemorrhage would account for. 
Uterine pain is generally present, of a tearing and stretching character, 
sometimes moderate in amount, more often severe, and occasionally 
amounting to intolerable anguish. It is often localized, and doubtless 
depends on the distension of the uterus by the retained coagula. If the 
distension be marked, there may be an irregularity in the form of the 
uterus at the site of sanguineous effusion; but this will be difficult to 
make out, except in women with thin and unusually lax abdominal 
parietes. A rapid increase in the size of the uterus has been described 
a- a -ign by Cazeaux and others. It is not very Likely that this will be 
appreciable toward the end of utero-gestation, as a very large amount <»i' 
effusion would be necessary to produce it. At an earlier period of 
nancy, at or about the fifth month, I made it out very distinctly in a 
case in my own practice. It obviously must have occurred to an enor- 
mous extent in a case related by Chevalier, in which post-mortem < Cesa- 
rean section was performed under the impression that the pregnancy had 
advanced to term, but only a three months' foetus was found, imbedded 
in coagula which distended the uterus to the size of a nine months' 
tation. 1 Labor-pains may be entirely absent. If present, they ai 
erally feeble, irregular, and inefficient. 

Diffen mtiai Diagnosis. — The only condition, besides ordinary syncope, 
likely to be confounded with this form of hemorrhage is rupture of the 
uterus, to which the intense pain and profound collapse induce consider- 
able resemblance. The latter rarely occurs until after labor has 
Borne time in progress and after the escape of the li<|ii<»r amnii ; WE 
hemorrhage usually occurs either before labor ha- commenced or at an 
early stage. The recession of the presentation and the escape <>i the 

1 Journ. de Med. din. d pirn, ,,. 



414 LABOR. 

foetus into the abdominal cavity in cases of rupture will further aid in 
establishing the diagnosis. 

Prognosis. — The prognosis, when blood escapes externally, is, on the 
whole, not unfavorable. The nature of the case is apparent, and reme- 
dial measures are generally adopted sufficiently early to prevent serious 
mischief. It is different with the concealed form, in which the mortality 
is very great. Out of Goodell's 106 cases, no less than 54 mothers died. 
This excessive death-rate is no doubt partly due to the fact that extreme 
prostration so often occurs before the existence of hemorrhage is sus- 
pected, and partly to the accident generally happening in women of 
weakly and diseased constitution. The prognosis to the child is still 
more grave. Out of 107 children, only 6 were born alive. The 
almost certain death of the child may be explained by the fact that 
when blood collects between the uterus and the placenta the foetal por- 
tion of the latter is probably lacerated, and the child then also dies from 
hemorrhage. 

Treatment. — In this, as in all other forms of puerperal hemorrhage, 
the great haemostatic is uterine contraction, and that we must try to 
encourage by all possible means. The first thing to be done, whether 
the hemorrhage be apparent or concealed, is to rupture the membranes. 
If the loss of blood be only slight, this may suffice to control it, and 
the case may then be left to nature. A firm abdominal binder should, 
however, be applied to prevent any risk of blood collecting internally, 
as there is nothing to prevent its filling the uterine cavity after the mem- 
branes are ruptured. Contraction may be further advantageously solic- 
ited by uterine compression and by the administration of full doses of 
ergot. If hemorrhage continue, or if we have any reason to suspect 
concealed hemorrhage, the sooner the uterus is emptied the better. If 
the os be sufficiently dilated, the best practice will be to turn without 
further delay, using the bi-polar method if possible. If the os be not 
open enough, a Barnes's bag should be introduced, while firm pres- 
sure is kept up to prevent uterine accumulation. Should the collapsed 
condition of the patient be very marked, the mere shock of the opera- 
tion might turn the scale against her. Under such circumstances it may 
be better practice to delay further procedure until, by the administration 
of stimulants, warmth, etc., we have succeeded in producing some amount 
of reaction, keeping up, in the mean while, firm pressure on the uterus. 
Should the head be low down in the pelvis, it may be easier to complete 
labor by means of the forceps. 



HEMORRHAGE AFTER DELIVERY. 415 



CHAPTER XY. 

HEMORRHAGE AFTEE DELIVERY. 

Its Importance. — Hemorrhage during or shortly after the third stage 
of labor is one of the most trying and dangerous accidents connect- 
ed with parturition. Its sudden and unexpected occurrence just after 
the labor appears to be happily terminated, and its alarming effect 
on the patient, who is often placed in the utmost danger in a few 
moments, tax the presence of mind and the resources of the practitioner 
to the utmost, and render it an imperative duty on every one who prac- 
tises midwifery to make himself thoroughly acquainted with its causes 
and preventive and curative treatment. There is no emergency in obstet- 
rics which leaves less time for reflection and consultation, and the life of 
the patient will often depend on the prompt and immediate action of the 
medical attendant. 

Frequency of Post-partum Hemorrhage. — Post-partum hemorrhage is 
one of the most frequent complications of delivery. I do not know of 
any statistics which enable us to judge with accuracy of its frequency, 
but I believe it to be an unquestionable fact that, especially in the upper 
ranks of society, it is very common indeed. This is probably due to the 
effects of civilization and to the mode of life of patients of that class, 
whose whole surroundings tend to produce a lax habit of body which 
favors uterine inertia, the principal cause of post-partum hemorrhage. 
In the report of the Registrar-General for the five years from 1«S7"_> to 
1876, 3524 deaths are attributed to flooding. The majority of these 
must have been caused by post-partum hemorrhage, although some may 
have been from other forms. 

( r> m mil ii a Preventable Accident. — Fortunately, it is, to a great 
extent, a preventable accident. I believe this feet cannot be too strongly 
impressed on the practitioner. If the third stage of labor be properly 
conducted, if every case be treated — as every ease ought to in — as if 
hemorrhage were impending, it would be much more infrequent than it 
is. It is a curious fact that post-partum hemorrhage is much more 
common in the practice of some medical men than in that of other-, the 
reason being that those who meet with it often are careless in their man- 
agement of their patients immediately after the birth of the child. That 
is just the time when the assistance of a properly-qualified practitioner 
is of value — much more so than before the second stage <»t" labor is con- 
cluded; hence, when I hear that a medical man i- constantly meeting 
with severe post-partum hemorrhage, I hold myself justified, ipso facto, 
in inferring that he does not know or doe- not practise the proper mode 
of managing the third stage of labor. 

Causes and Nature's Method of Controlling Hemorrhage after Delivery. 
— The placenta, a- we have seen, i- separated by the last pain-, and the 
blood, which in greater or less quantity accompanies tie- linn-, prob- 



416 LABOR. 

ably comes from the utero-plaeental vessels which are then lacerated. 
Almost immediately afterward the uterus contracts firmly, and in a 
typical labor assumes the hard cricket-ball form which is so comforting 
to the accoucheur to feel. The result is the compression of all the vas- 
cular trunks which ramify in its walls, both arteries and veins, and thus 
the flow of blood though them is prevented. By referring to what has 
been said as to the anatomy of the muscular fibres of the gravid uterus, 
especially at the placental site (p. 65), it will be seen how admirably they 
are adapted for this purpose. The arrangement of the vessels themselves 
favors the haemostatic action of uterine contraction. The large venous 
sinuses are placed in layers, one above the other, in the thickness of the 
uterine walls, and they anastomose freely. ^When the superimposed 
layers communicate with those immediately below them, the junction is 
by a falciform or semilunar opening in the floor of the vessel nearest the 
external surface of the uterus. Within the margins of this aperture 
there are muscular fibres, the contraction of which probably tends to 
prevent retrogression of blood from one layer of vessels into the other. 
The venous sinuses themselves are of a flattened form, and they are inti- 
mately attached to. the muscular tissues. It is obvious, then, that these 
anatomical arrangements are eminently adapted to facilitate the closure 
of the vessels. They are, however, large, and are destitute of valves ; 
and if contraction be absent or if it be partial and irregular, it is equally 
easy to understand why blood should pour forth in the appalling amount 
which is sometimes observed. 

Importance of Tonic Uterine Contraction. — If uterine action be firm, 
regular, and continuous, the vessels must be sealed up and hemorrhage 
effectually prevented. This fact has been doubted by many authorities. 
Gooch was the first to describe what he called " a peculiar form of hem- 
orrhage " accompanying a contracted womb ; similar observations have 
been made by other writers, such as Velpeau, Rigby, and Gendrin. 
Simpson says on this point that strong uterine contractions "are not 
probably so essential a part in the mechanism of the prevention of hem- 
orrhage from the open orifices of the uterine veins as we might, a yyriori, 
suppose." * "With regard to Gooeh's cases it has been pointed out that 
his own description proves that, however firmly the uterus may have 
contracted immediately after the expulsion of the child, it must have 
subsequently relaxed, for he passed his hand into it to remove retained 
clots — a manoeuvre which he could not have practised had tonic con- 
traction been present. In some of these cases the hemorrhage has been 
found to come from a laceration of the cervix. Of course, blood may 
readily escape from mechanical injury of this kind, although the uterus 
itself be in a satisfactory state of contraction ; and the possibility of this 
occurrence should always be borne in mind. Instances of the successful 
treatment of this variety of post-partum hemorrhage by sutures applied 
to the lacerated cervix have been related by Pallen and others. 

Although, then, we may admit that post-partum hemorrhage is 
incompatible with persistent contraction of the uterus, it by no means 
follows that the converse is true. On the contrary, it is not uncommon 
to meet with cases in which the uterus is large and apparently quite 

1 Selected Obst Works, p. 234. 



HEMORRHAGE AFTER DELIVERY. 417 

flaccid, and in which there is no loss of blood. Alternate relaxation and 
contraction of the uterus after delivery are also of constant occurrence, 
and yet hemorrhage during the relaxation does not take place. The 
explanation, no doubt, is, that immediately after the birth of the child 
there was sufficient contraction to prevent hemorrhage, and that during 
its continuance coagula formed in the mouths of the uterine sinuses, by 
which they were sufficiently occluded to prevent any loss when subse- 
quent relaxation occurred. 

In all probability, both uterine contraction and thrombosis are in 
operation in ordinary cases ; and we shall presently see that all the 
means employed in the treatment of post-partum hemorrhage act by 
producing one or other of them. 

Secondary Causes of Hemorrhage. — Uterine inertia after labor, then, 
may be regarded as the one great primary cause of post-partum hemor- 
rhage ; but there are various secondary causes which tend to produce it, 
one of the most frequent of which is exhaustion following a protracted 
labor. The uterus gets worn out by its efforts, and when the foetus is 
expelled it remains in a relaxed state, and hemorrhage results. Over- 
distension of the uterus acts in the same way. Hence, hemorrhage is 
very frequently met with when there has been an excessive amount of 
liquor amnii or in multiple pregnancies. One of the worst cases I ever 
met with was after the birth of triplets, the uterus having been of an 
enormous size. Rapid emptying of the uterus, during which there has 
not been sufficient time for complete separation of the placenta, often 
tends to the same result. This is the reason why hemorrhage so fre- 
quently follows forceps delivery, especially if the operation have been 
unduly hurried, and it is one of the chief dangers in what are termed 
" precipitate labors.". The general condition of the patient may also 
strongly predispose to it. Thus, it is more often met with in women 
who have borne families, especially if they be weakly in constitution, 
comparatively seldom in primiparse ; and for the same reason that after- 
pains are most common in the former — namely, that the uterus, weak- 
ened by frequent childbearing, contracts inefficiently. The experience 
of practitioners in the tropics shows that European women, debilitated 
by the relaxing effects of warm climates, are peculiarly prone to it, and 
it forms one of the chief dangers of childbirth amongst the English 
ladies in India. 

J r regular Uterine Contraction. — Another important cause of post- 
partum hemorrhage is partial and irregular contraction of the uterus. 
Part of the muscular tissue is firmly contracted, while another part is 
relaxed, and the latter very often the placental site. This has been 
especially dwelt on by Simpson. He says: " The morbid condition 
which is most frequently and earliest seen in connect ion with post- 
partum hemorrhage is a state of irregularity and want of equability in 
the contractile action of different parts of the uterus — and, it may he, in 
different planes of the muscular fibres — as marked by one or more 
points in the organ feeling hard and contracted, at the same time that 
other portions of the parietes are soft and relaxed.'' 

Hour-glass Contraction. — One peculiar variety., which has been much 
dwelt on by writers and is a prominent bugbear to obstetricians, is the 

27 



418 



LABOR. 



so-called " hour-glass contraction" This in reality seems to depend on 
spasmodic contraction of the internal os uteri, by means of which the 
placenta becomes encysted in the upper portion of the uterus, which is 
relaxed. On introducing the hand it first passes through the lax cer- 
vical canal until it comes to the closed internal os, with the umbilical 
cord passing through it, which has generally been supposed to be a cir- 
cular contraction of a portion of the body of the uterus. 

Encystment of the placenta, however, although more rare, unques- 
tionably takes place in a portion only of the body of the uterus (Fig. 
145). Then, apparently, the placental site remains more or less para- 

145. 





Irregular Contraction of the Uterus, with Encystment of the Placenta. 

lyzed, with the placenta still attached, while the remainder of the body 
of the uterus contracts firmly, and thus encystment is produced. [ L ] 

Causes of Irregular Contractions. — These irregular contractions of 
the uterus are by no means so common as our older authors supposed. 

P The central constriction of the right-hand figure is intended to represent the inter- 
nal os uteri. The condition of the left-hand illustration, with a contraction around one 
corner, I have very distinctly defined in a case of retained placenta. The adherent 
placenta was entirely enclosed, and the contracted portion barely sufficed to admit the 
hand. When the adhesion was broken up, the inert portion of the uterine wall at once 
contracted : this was no doubt partly the result of the removal of the mechanical obsta- 
cle, and partly due to the stimulating effect of the presence and work of the hand. 
This experience is in correspondence with the opinion of the late Prof. C. D. Meigs, 
who taught that an irregularly-contracted uterus was the effect of an adherent placenta acting 
as an obstacle to contraction over the seat of union, while the rest of the organ was free to 
contract. Whether the central muscular fibres of the uterus can ever contract so as to 
constrict the organ is a question which has long been in dispute. Those who deny its 
possibility do so upon anatomical reasoning, claiming that the arrangement of the cir- 
cular muscular fibres is such that a violent linear contraction in the corpus uteri is an 
anatomical impossibility. Those who have had under care cases of 'tetanoid constric- 
tion of the uterus" are much exercised as to the exact location of the spasmodic band 
of fibres which has been found both circular and oblique and tightly surrounding the 
body of the foetus. The discovery of Bandl of Vienna (see p. 433, chap, xvi.) might 
possibly account for the condition found in one of the cases of Dr. T. A. Foster of Port- 
land. Maine ( Transactions Maine Med. Association, 1868-69, p. 273), where the child was 
tightly held by the neck, but for the fact that the uterine walls were thicker than nor- 
mal. Dr. Thomas C. Smith of Washington, D. C, has, I think, made it clear that 
tetanoid constriction mav occur in the body of the uterus. (See Am. Journ. of Obstet- 
rics, April, 1882, pp. 294-322.;— Ed.] 



HEMORRHAGE AFTER DELIVERY. 419 

When they do occur, I believe them almost invariably to depend on 
defective management of the third stage of labor. " The most frequent 
cause," says Kigby, 1 " is from over-anxiety to remove the placenta ; the 
cord is frequently pulled at, and at length the os uteri is excited to con- 
tract." While this is being done no attempts are probably being made 
to excite the fundus to proper action, and therefore the hour-glass con- 
traction is established. Duncan says of this condition, " Hour-glass 
contraction cannot exist unless the parts above the contraction are in a 
state of inertia ; were the higher parts of the uterus even in moderate 
action the hour-glass contraction would soon be overcome." 2 If pla- 
cental expression were always employed, if it were the rule to effect the 
expulsion of the placenta by a vis a tergo instead of extracting by a vis 
a f route, I feel confident that these irregular and spasmodic contractions 
— of the influence of which in producing hemorrhage there can be no ques- 
tion — would rarely, if ever, be met with. It is to be observed that even 
in these cases it is not because the uterus is in a state of partial contrac- 
tion, but because it is in a state of partial relaxation, that hemorrhage 
ensues. 

Placental Adhesions. — Adhesions of the placenta to the uterine pari- 
etes may cause hemorrhage, especially if they be partial and the 
remainder of the placenta be detached. The frequency of these has 
been over-estimated. Many cases believed to be examples of adherent 
placentae are, in reality, only cases of placentae retained from uterine 
inertia. The experience of all who see much midwifery will probably 
corroborate the observation of Braun, that " abnormal adhesion and 
hour-glass contraction are more frequently encountered in the experience 
of the young practitioner, and they diminish in frequency in direct ratio 
to .increasing years." 3 The cause of adhesion is often obscure, but it 
most probably results from a morbid state of the decidua, which is pro- 
duced by antecedent disease of the uterine mucous membrane ; then the 
adhesion is apt to recur in subsequent pregnancies. The decidua is 
altered and thickened, and patches of calcareous and fibrous degenera- 
tion may be often found on the attached surface of the placenta. Most 
frequently the placenta is only partially adherent ; patches of it remain 
firmly attached to the uterus, while the rest is separated ; hence the 
uterine walls remain relaxed and hemorrhage frequently follows. The 
diagnosis and management of these very troublesome cases will be found 
described under the head of Treatment (p. 423). 

Constitutional Predisposition to Flooding. — Finally, I think it must 
be admitted that there are some women who really merit the appellation 
of "flooders" which has been applied to them, and who, do what we 
may, have the most extraordinary tendency to hemorrhage after delivery. 
I do not think that these cases, however, are by any means SO common 
as some have supposed. I have attended several patients who have 
nearly lost their lives from post-partum hemorrhage in former labors, 
some who have suffered from it in every preceding confinement, and I 
have only met with two cases in which the assiduous use of preventive 
treatment failed to avert it. In these (one of which I have elsewhere 

1 Rigby's Midwifery, p. 225. 2 Researches in Obstetrics, p. 889. 

3 Braun's Lectures, 1869. 



420 LABOR. 

published in detail 1 ), in spite of all my efforts, I could not succeed in 
keeping up uterine contraction, and the patients would certainly have 
lost their lives were it not for the means which modern improvements 
have fortunately placed at our disposal for producing thrombosis in the 
mouths of the bleeding vessels. The nature of these rare cases requires 
further investigation ; possibly they may, to some extent, be the subjects 
of the so-called hemorrhagic diathesis. 

Signs and Symptoms. — The loss of blood may commence immediately 
after the birth of the child, before the expulsion of the placenta, or not 
until some time afterward, when the contracted uterus has again relaxed. 
It may commence gradually or suddenly : in the latter case it may begin 
with a gush, and in the worst form the bedclothes, the bed, and even the 
floor, are deluged with the blood which, it is no exaggeration to say, is 
pouring from the patient. If, now, the hand be placed on the abdomen, 
Ave shall miss the hard round ball of the contracted uterus, which will be 
found soft and flabby, or we may even be unable to make out its contour 
at all. If the hemorrhage be slight or if Ave succeed in controlling it at 
once, no serious consequences follow ; but if it be excessive or if we fail 
to check it, the graA T est results ensue. 

Exhaustion in Extreme Cases. — There are feAV sights more appalling to 
Avitness than one of the worst cases of post-partum hemorrhage. The 
pulse becomes rapidly aifected, and may be reduced to a mere thread or 
it may become entirely imperceptible. Syncope often comes on — not in 
itself ahvays an unfavorable occurrence, as it tends to promote throm- 
bosis in the \ r enous sinuses. Or, short of actual syncope, there may be 
a feeling of intense debility and faintness. Extreme restlessness soon 
snpeiwenes, the patient throAvs herself about the bed, tossing her arms 
wildly aboA^e her head ; respiration becomes gasping and sighing, the 
" besoin de respirer" is acutely felt, and the patient cries out for more 
air ; the skin becomes deadly cold and coA T ered with profuse perspiration ; 
if the hemorrhage continue unchecked, we next may haA T e complete loss 
of A^ision, jactitation, compulsions, and death. 

Formidable as such symptoms are, it is satisfactory to know that 
recoA T ery often takes place, eA T en when the poAvers of life seem reduced to 
the loAvest ebb. If Ave can check the hemorrhage Avhile there is still 
some poAver of reaction left, hoAveA T er slight, Ave may not unreasonably 
hope for eA T entual recoA T ery. The constitution, howeA T er, may haA T e 
receiA^ed a seA r ere shock, and it may be months, or eA T en years, before the 
patient recoA^ers from the effects of only a few minutes' hemorrhage. A 
death-like pallor frequently folloAvs these excessiA T e losses, and the 
patient often remains blanched and exsanguine for a long time. 

Preventive Treatment. — The preA T entiA T e treatment of post-partum hem- 
orrhage should be carefully practised in eA T ery case of labor, howeA T er 
normal. If the practitioner make a habit of neA T er remoA'ing his hand 
from the uterus after the birth of the child until the placenta is expelled, 
and of keeping up continuous uterine contraction for at least half an 
hour after delivery is completed — not necessarily by friction on the 
fundus, but by simply grasping the contracted Avomb with the palm of 
the hand and preA T enting its undue relaxation — cases of post-partum 



HEMORRHAGE AFTER DELIVERY. 421 

flooding will seldom be met with. As a rule, we should, I think, not 
apply the binder until at least that time has elapsed. The binder is an 
effective means of keeping up, but not of producing, contraction, and it 
should never be trusted to for the latter purpose. If it be put on too 
soon, the uterus may relax under it, and become filled with clots without 
the practitioner knowing anything about it ; whereas this cannot possibly 
take place as long as the uterine globe is held in the hollow of the hand. 
I have seen more than one serious case of concealed hemorrhage result 
from the too common habit of putting on the binder immediately after 
the removal of the placenta. I believe also, as I have formerly said, 
that it is thoroughly good practice to administer a full dose of the liquid 
extract of ergot in all cases after the placenta has been expelled, to ensure 
persistent contraction and to lessen the chance of blood-clots being 
retained in utero. 

These are the precautions which should be used in all cases alike ; but 
when we have reason to fear the occurrence of hemorrhage from the his- 
tory of previous labors or other cause, special care should be taken. The 
ergot should be given, and preferably in the form of the subcutaneous 
injection of ergotin, before the birth of the child, when the presentation 
is so far advanced that we estimate that labor will be concluded in from 
ten to twenty minutes, as we can hardly expect the drug to produce any 
effect in less time. Particular attention, moreover, should then be paid 
to the state of the uterus. Every means should be taken to ensure 
regular and strong contraction, and it is advisable to rupture the mem- 
branes early, as soon as the os is dilated or dilatable, to ensure stronger 
uterine action. If any tendency to relaxation occur after delivery, a 
piece of ice should be passed into the vagina or into the uterus. Should 
coagula collect in the uterus, they may.be readily expelled by firm 
pressure on the fundus, and the finger should be passed occasionally up 
to the cervix, and any which are felt there should be gently picked away. 

We should be specially on our guard in all cases in which the pulse 
does not fall after delivery. If it beat at 100 or more some ten minutes 
or a quarter of an hour after the birth of the child, hemorrhage not 
unfrequently follows ; and hence it is a good practical rule, which may 
save much trouble, that a patient should never be left unless the pulse 
has fallen to its natural standard. 

Curative Treatment. — As there are only two means which nature 
adopt- in the prevention of post-partum hemorrhage, so the remedial 
measures also may be divided into two classes: 1, those which act by 
the production of uterine contraction; 2, those which act by producing 
thrombosis in the vessels. Of these, the first are the most commonly 
used ; and it is only in the worst cases, in which they have been 
assiduously tried and have failed, that we resort to those coming under 
the second heading. 

Uterine Pressure. — The patient should be placed on her back, in 
which position we can more readily command the uterus as well as 
attend to her general state. If the uterus be found relaxed and lull of 
clots, by firmly grasping it in the hand contraction may be evoked, it- 
contents expelled, and further hemorrhage at once arrested. Should 
this, fortunately, be the case, we must keep up contraction by gently 



422 LABOR. 

kneading the uterus until we are satisfied that undue relaxation will not 
recur. 

The powerful influence of friction in promoting contraction cannot 
be doubted, and nothing will replace it ; no doubt it is fatiguing, but 
as long as it is effectual it must be kept up. No roughness should be 
used, as we might produce subsequent injury, but it is quite possible to 
use considerable pressure without any violence. 

Another method of applying uterine pressure has been strongly advo- 
cated by Dr. Hamilton of Falkirk, and it may be serviceable where 
there is a constant draining from the uterus and a capacious pelvis. It 
consists in passing the fingers of the right hand high up into the 
posterior cul-de-sac of the vagina so as to reach the posterior surface of 
the uterus, while counter-pressure is exercised by the left hand through 
the abdomen. The anterior and posterior walls of the uterus are thus 
closely pressed together. 

Administration of Ergot. — During the time that pressure is being 
applied attention can be paid to general treatment ; and in giving his 
directions to the bystanders the practitioner should be calm and collected, 
avoiding all hurry and excitement. A full dose of ergot should be 
administered, and if one have already been given it should be repeated. 
We cannot, however, look upon ergot as anything but a useful accessory, 
and it is one which requires considerable time to operate. The hypo- 
dermic use of ergotin offers the double advantage, in severe cases, of 
acting with greater power and much more rapidly than the usual method 
of administration. It should, therefore, always be used in preference. 
An aqueous solution of ergotinin, -^ tro^h °^ a g ram ni 10 minims, has been 
highly recommended by Chahbazain of Paris as acting more energetically, 
but of this I have no experience. 1 

Stimulants. — The sudden flow will probably have produced exhaus- 
tion and a tendency to syncope, and the administration of stimulants 
will be necessary. The amount must be regulated by the state of the 
pulse and the degree of exhaustion. There is no more absurd mistake, 
however, than implicitly relying on the brandy-bottle to check post- 
partum hemorrhage. In the worst cases absorption is in abeyance, and 
brandy may be poured down in abundance, the practitioner believing 
that he is rousing his patient, while he is, in fact, only filling the stomach 
with a quantity of fluid which is eventually thrown up unaltered. I 
have more than once seen symptoms produced by the over-free use of 
brandy in slight floodings which were certainly not those of hemorrhage. 
I remember on one occasion being summoned by a practitioner, with a 
view to transfusion, to a patient who was said to be insensible and col- 
lapsed from hemorrhage. I found her, indeed, unconscious, but with 
a flushed face, a bounding pulse, a firmly-contracted uterus, and deep 
stertorous breathing. On inquiry I ascertained that she had taken an 
enormous quantity of brandy, which had brought on the coma of pro- 
found intoxication, while the hemorrhage had obviously never been 
excessive. 

Hypodermic Injection of Ether. — The hypodermic injection of sul- 
phuric ether is a remedy of great value as a powerful stimulant in cases 

1 Obst. Trans., 1882. 



HEMORRHAGE AFTER DELIVERY. 423 

in which exhaustion is very great. It has the advantage of acting rap- 
idly and of being capable of administration when the patient is unable 
to swallow. A fluidrachm may be injected into the nates or thigh, and 
the injection may be repeated as the state of the patient may require. 

Fresh Air, etc. — The window should be thrown widely open, to allow 
a current of fresh cold air to circulate freely through the room. The 
pillows should be removed, the head kept low, and the patient should 
be assiduously fanned. 

Emptying of Uterus. — If bleeding continue, or if it commence before 
the placenta is expelled, the hand should be carefully and gently passed 
into the uterus and its cavity cleared of its contents. The mere presence 
of the hand within the uterus is a powerful inciter of uterine action. 
When the placenta is retained it is the more essential, as the hemor- 
rhage cannot possibly be checked as long as the uterus is distended by 
it. During the operation the uterus should be supported by the left 
hand externally, and by using the two hands in concert the chances of 
injuring the textures are greatly lessened. 

Treatment of Hour-glass Contraction. — If the so-called "hour-glass 
contraction" be present or if the placenta be morbidly adherent, the 
operation will be more difficult and will require much judgment and 
care. The spasmodic contraction of the inner os in the former case may 
generally be overcome by gentle and continuous pressure of the fingers 
passed within the contraction, while the uterus is supported from with- 
out. By this means, too, further hemorrhage can in most cases be con- 
trolled until the spasm is sufficiently relaxed to admit of the passage of 
the hand. 

Signs of Adherent Placenta. — There are no very reliable signs to indi- 
cate morbid adhesion of the placenta previous to the introduction of the 
hand. The following are the symptoms as laid down by Barnes, any 
of which might, however, accompany non-detachment of the placenta 
unaccompanied by adhesion : "You may suspect morbid adhesion if 
there have been unusual difficulty in removing the placenta in previous 
labors ; if during the third stage the uterus contracts at intervals firmly, 
each contraction being accompanied by blood, and yet on following up 
the cord you feel the placenta in utero ; if on pulling on the cord, two 
fingers being pressed into the placenta at the root, you feel the placenta 
and uterus descend in one mass, a sense of dragging pain being elicited ; 
if during a pain the uterine tumor does not present a globular form, but 
be more prominent than usual at the place of placental attachment." 1 

Treatment of Adherent Placenta. — The artificial removal of an adhe- 
rent placenta is always a delicate and anxious operation, which, however 
carefully performed, must of necessity expose the patient to the risk <>! 
injury to the uterine structure-, and of leaving behind portions of pla- 
cental tissue, which may give rise to secondary hemorrhage or septi- 
caemia. The cord will guide the hand to the site of attachment, and the 
fingers must be very gently insinuated between the lower edge of the 
placenta and the uterine wall ; or, if a portion he already detached, we 
may commence to peel off the remainder at that spot Supporting the 
uterus externally, we carefully pick off as much as possible, proceeding 

1 Obstetric Operation*, p. 440. 



424 LABOR. 

with the greatest caution, as it is by no means easy to distinguish be- 
tween the placenta and the uterus. At the best, it is far from easy to 
remove all, and it is wiser to separate only what we readily can than to 
make too protracted efforts at complete detachment. When it is found 
to be impossible to detach and remove the whole or a great part of the 
placenta, we cannot but look upon the further progress of the case with 
considerable anxiety. The retained portions may be ere long spontane- 
ously detached and expelled, or they may decompose and give rise to a 
fetid discharge and septic infection. Such cases must be treated by anti- 
septic intra-uterine injections, so as to lessen the risk of absorption as 
much as possible ; but until the retained masses have been expelled and 
the discharge has ceased the patient must be considered to be in consid- 
erable danger. In a few rare cases there is reason to believe that con- 
siderable masses of retained placental tissue have been entirely absorbed. 
It is difficult to understand so strange a phenomenon, but several well- 
authenticated cases are recorded in which there seems no reason to doubt 
that the retained placenta was removed in this way. 1 

Excitement of Reflex Action by Cold, etc. — Various means are used for 
exciting uterine contraction by reflex stimulation. Amongst the most 
important of these is cold. In patients who are not too exhausted to 
respond to the stimulus applied it is of extreme value. But to be of 
use it should be used intermittently and not continuously. Pouring a 
stream of cold water from a height on the abdomen is a not uncommon, 
but bad, practice, as it deluges the patient and the bedding in water, 
which may afterward act injuriously. Flapping the lower part of the 
abdomen with a wet towel is less objectionable. Ice can generally be 
obtained, and a piece ..should be introduced into the uterus. This is a 
very powerful haemostatic, and often excites strong action when other 
means fail. I constantly employ it, and have never seen any bad 
results follow. A large piece of ice may also be held over the fundus, 
and removed and reapplied from time to time. Iced water may be 
injected into the rectum. A very powerful remedy is washing out the 
uterine cavity with a stream of cold water by means of a vaginal pipe 
of a Higginson's syringe carried up to the fundus. Another means of 
applying cold, said to be very effectual, is the application of the ether 
spray, such as is used for producing local anaesthesia, over the lower 
part of the abdomen. 2 All these remedies, however, depend for their good 
results on the fact of the patient being in a condition to respond to stim- 
ulus, and their prolonged use, if they fail to excite contraction rapidly, 
will certainly prove injurious. Rigby used to look upon the application 
of the child to the breast as one of the most certain inciters of uterine 
action. It may be of service, after the hemorrhage has been checked, 
in keeping up tonic contraction, and should therefore not be omitted ; 
but we certainly cannot waste time in inducing the child to suck in the 
face of the actual emergency. 

Intra-uterine Injections of Hot Water. — Of late, intra-uterine injec- 
tions of hot water, at a temperature of from 100° to 120°, have been 

1 See an interesting paper by Dr. Thrush on " Retention of the Placenta in Labor at 
Term," Amer. Journ. of Obstet., July, 1877. 

2 Griffiths, Practitioner, March, 1877. 



HEMORRHAGE AFTER DELIVERY. 425 

highly recommended as a powerful means of arresting post-partum hem- 
orrhage, often proving effectual when all other treatment has failed. 
The number of published cases in which it has proved of great value is 
now considerable. The present Master of the Rotunda, Dr. Lorn be 
Atthill, has recorded 16 cases 1 in which it checked hemorrhage at once, 
in many of which ergot, ice, and other means had failed. He speaks 
of it as especially useful in those troublesome cases in which the uterus 
alternately relaxes and hardens, and resists all our efforts to produce 
permanent contraction. My own experience of this treatment is very 
favorable. I have now used it in several cases, in some of which the 
tendency to hemorrhage was very great, and in every instance it has at 
once produced strong uterine action and instantly checked the flow. It 
is, moreover, much more agreeable to the patient than cold applications. 
I think it cannot be doubted that we have in these hot irrigations a 
valuable addition to our methods of treating uterine hemorrhage. 

State of the Bladder. — The late Dr. Earle pointed out 2 that a dis- 
tended bladder often prevents contraction, and to avoid the possibility 
of this the catheter should be passed. 

Plugging of the Vagina. — Plugging of the vagina has often been used. 
It is only necessary to mention it for the purpose of insisting on its 
absolute inapplicability in all cases of post-partum hemorrhage; the 
only effect it could have would be to prevent the escape of blood exter- 
nally, which might then collect to any extent in the cavity of the uterus. 

Compression of the Abdominal Aorta. — Compression of the abdomi- 
nal aorta is highly thought of by many continental authorities, but it is 
little known or practised in this country. It has been objected to by 
some on the theoretical ground that the hemorrhage is chiefly venous, 
and not arterial, and that it would only favor the reflux of venous blood 
into the vena cava. Cazeaux points out that, on account of the close 
anatomical relations between the aorta and the vena cava, it is hardly 
possible to compress one vessel within the other. The backward flow 
of blood, therefore, through the vena cava may also be thus arrested. 
There is strong evidence in favor of the occasional utility of compres- 
sion. Its chief recommendation is, that it can be practised immediately, 
and by an assistant, who can be shown how to apply the pressure. It 
is most likely to prove useful in sudden and severe hemorrhage, and if 
it only control the loss for a few moments it gives us time to apply other 
methods of treatment. As a temporary expedient, therefore, it should 
be borne in mind and adopted when necessary. It has the great advan- 
tage of supplementing, without superseding, other and more radical plans 
of treatment. The pressure is very easily applied on account of the lax- 
state of the abdominal walls. The artery can readily be felt pulsating 
above the fundus uteri, and can be compressed against the vertebrae by 
three or four fingers applied lengthways. Baudelocque, who was a 
strong advocate of this procedure, states that he has on several occasions 
controlled an otherwise intractable hemorrhage in this way, and that lie 
on one occasion kept up compression for four consecutive hour-. ( azeaux 
believes that compression of the aorta may have a further advantageous 
effect in retaining the mass of the blood in the upper part of the body, 
1 Lancet, February 9, 1878. 2 Earle's Flooding after Delivery, p. 1 63. 



426 LABOR. 

and thus lessening the tendency to syncope and collapse. If an aortic 
tourniquet, such as is used for compressing the vessel in cases of aneur- 
ism, could be obtained, it might be used with advantage in such cases. 

Faradic Current. — If a battery is at hand, the faradic current may be 
used, and is, it is said, a very powerful agent in inducing uterine con- 
traction, one pole being introduced into the uterus, the other applied 
over it through the abdominal parietes. 

Bandaging of the Extremities. — When the hemorrhage has been exces- 
sive and there is profound exhaustion, firm bandaging of the extremi- 
ties, by preference with Esmarch's elastic bandages if they can be 
obtained, may be advantageously adopted, with the view of retaining 
the blood as much as possible in the trunk, and thus lessening the tend- 
ency to syncope. As a temporary expedient in the worst class of cases 
it may occasionally prove of service. 

[Lives of patients in extremis have been saved by the expedient of 
raising the body of the woman and lowering her head, so as to turn the 
current of blood toward the brain. This may have to be repeated sev- 
eral times in the treatment of a case where attacks of syncope indicate 
it. A bladder containing ice may be held under the hand of the ope- 
rator over the abdomen and above the fundus uteri, and compression 
made upon the uterus and aorta at the same time. In one case I»was 
forced, by the long-continued inertia of the uterus and the tendency to 
a return of hemorrhage, to keep up this form of compression for 6-J 
hours. The hand of the operator should be protected by a compress of 
flannel, or he may have an attack of local neuralgia, or possibly rheu- 
matism, in his arm. — Ed.] 

Injection of Styjrtics. — Supposing these means fail, and the uterus 
obstinately refuses to contract in spite of all our efforts — and, do what 
we may, cases of this kind will occur — the only other agent at our com- 
mand is the application of a powerful styptic to the bleeding surface to 
produce thrombosis in the vessels. " The latter," says Dr. Ferguson, 1 
alluding to this means of arresting hemorrhage, " appears to be the sole 
means of safety in those cases of intense flooding in which the uterus 
flaps about the hand like a wet towel. Incapable of contraction for 
hours, yet ceasing to ooze out a drop of blood, there is nothing appar- 
ently between life and death but a few soft coagula plugging up the 
sinuses." These form but a frail barrier indeed, but the experience of 
all who have used the injection of a solution of perchloride of iron in such 
cases proves that they are thoroughly effectual, and its introduction into 
practice is one of the greatest improvements in modern midwifery. 
Although this method of treating these obstinate cases is not new, since 
it was practised long ago in Germany, its adoption in this country is 
unquestionably due to the energetic recommendation of Dr. Barnes. 
Although the dangers of the practice have been strongly insisted on, 
and with a degree of acrimony that is to be regretted, I know of only 
one published case in which its use has been followed by any evil effects. 
Its extraordinary power, however, of instantly checking the most for- 
midable hemorrhage has been demonstrated by the unanimous testimony 
of all who have tried it. As it is not proposed by any one that this 

1 Preface to Gooch On Diseases of Women, p. xlii. 



HEMORRHAGE AFTER DELIVERY. 427 

means of treatment should be employed until all ordinary methods 
of evoking contraction have failed, and as, in cases of this kind, the 
lives of the patients are of necessity imperilled, we should be fully justi- 
fied in adopting it even if its possibly injurious effects had been much 
more certainly proved. It is surely at any time justifiable to avoid a 
great and pressing peril by running a possible chance of a less one. 
Whenever, therefore, we have tried the plans above indicated in vain, no 
time should be lost in resorting to this expedient. Xo practitioner should 
attend a case of midwifery without having the necessary styptic with 
him. The best and most easily obtainable form of using the remedy is 
the "liquor ferri perchloridi fortior" of the London Pharmacopoeia, 
which should be diluted for use with six times its bulk of water. This 
is certainly better than a weaker solution. The vaginal pipe of a Hig- 
ginson's syringe, through which the solution has once or twice been 
pumped to exclude the air, is guided by the hand to the fundus uteri 
and the fluid injected gently over the uterine surface. The loose and 
flabby mucous membrane is instantaneously felt to pucker up, all the 
blood with which the fluid comes in contact is coagulated, and the 
hemorrhage is immediately arrested. I think it is of importance to 
make sure that the uterus and vagina are emptied of clots before injec- 
tion. In the only cases in which I have seen any bad symptoms follow 
this precaution had been neglected. The iron hardened all the coagula, 
which remained in utero, and septicaemia supervened ; which, however, 
disappeared after the clots had been broken up and washed away by 
intra-uterine antiseptic injections. After we have resorted to this treat- 
ment all further pressure on the uterus should be stopped. We must 
remember that we have now abandoned contraction as a haemostatic 
and are trusting to thrombosis, and that pressure might detach and less- 
en the coagula which are preventing the escape of blood. 

Other local astringents may be eventually found to be of use. Tinc- 
ture of matico possibly might be serviceable, although I am not aware 
that it has been tried. Dupierris has advocated tincture of iodine, and 
has recorded 24 cases in which he employed it — in all without accident 
and with a successful issue. Penrose strongly recommends common vin- 
egar, which has the advantage of being always readily obtainable. But 
nothing seems likely to act so immediately or so effectually as the per- 
chloride of iron. 

Hemorrhage from Laceration of Maternal Structures. — A word may 
here be said as to the occasional dependence of hemorrhage alter delivery 
on laceration of the cervix or other injury to the maternal soft parts. 
Duncan has narrated a case in which the bleeding came from a ruptured 
perineum. If hemorrhage continue after the uterus is permanently con- 
tracted, a careful examination should be made t<> ascertain if any such 
injury exist. Most generally the source of bleeding Is the cervix, and 
the flow can be readily arrested by swabbing the injured textures with a 
sponge saturated in a solution of the perchloride. 

Secondary Treatment. — The secondary treatment of post-partum hem- 
orrhage is of importance. When reaction commences ;i train of distress- 
ing symptoms often show themselves, such as intense and throbbing 
headache, great intolerance of light and sound, and general uervous pros- 



428 LABOR. 

tration ; and when these have passed away we have to deal with the 
more chronic effects of profuse loss of blood. Nothing is so valuable 
in relieving these symptoms as opium. It is the best restorative that 
can be employed, but it must be administered in larger doses than usual. 
Thirty to forty drops of Battley's solution should be given by the mouth 
or in an enema. At the same time the patient should be kept perfectly 
still and quiet in a darkened room and the visits of anxious friends 
strictly forbidden. Strong beef-essence or gravy soup, milk, or eggs beat 
up with milk, and similar easily-absorbed articles of diet should be 
given frequently and in small quantities at a time. Stimulants will be 
required according to the state of the patient, such as warm brandy and 
water, port wine, etc. Rest in bed should be insisted on, and continued 
much beyond the usual time. Eventually, the remedies which act by 
promoting the formation of blood, such as the various preparations of 
iron, will be found useful and may be required for a length of time. 

Transfusion. — Under the head of Transfusion I have separately treated 
the application of that last resource in those desperate cases in which the 
loss of blood has been so excessive as to leave no other hope. 

Secondary Post-partum Hemorrhage. — In the majority of cases, if a 
few hours have elapsed after delivery without hemorrhage, we may con- 
sider the patient safe from the accident. It is by no means very rare, how- 
ever, to meet with even profuse losses of blood coming on in the course 
of convalescence at a time varying from a few hours or days up to several 
weeks after delivery. These cases are described as examples of " second- 
ary hemorrhage" and they have not received at all an adequate amount 
of attention from obstetric writers, inasmuch as they often give rise to 
very serious, and even fatal, results, and are always somewhat obscure in 
their etiology and difficult to treat. We owe almost all our knowledge 
of this condition to an excellent paper by Dr. McClintock of Dublin, 
who has collected characteristic examples from the writings of various 
authors and accurately described the causes which are most apt to pro- 
duce it. 

Profuse Lockial Discharge. — We must, in the first place, distinguish 
between true secondary hemorrhage and profuse lochial discharge con- 
tinued for a longer time than usual. The latter is not a very uncom- 
mon occurrence, and is generally met with in cases in which involution 
of the uterus has been checked, as by too early exertion, general debil- 
ity, and the like. The amount of the lochial discharge varies in dif- 
ferent women. In some patients it habitually continues during the 
whole puerperal month, and even longer, but not to an extent which 
justifies us in including it under the head of hemorrhage. In such cases 
prolonged rest, avoidance of the erect posture, occasional small doses of 
ergot, and, it may be, after the lapse of some weeks, astringent injec- 
tions of oak-bark or alum, will be all that is necessary in the way of 
treatment. 

True secondary hemorrhage is often sudden in its appearance and seri- 
ous in its effects. McClintock mentions 6 fatal cases, and Mr. Bassett 
of Birmingham 1 has recorded 13 examples which came under his own 
observation, 2 of which ended fatally. 

1 Brit, Med. Journ., 1872. 



HEMORRHAGE AFTER DELIVERY. 429 

Causes. — The causes may be either constitutional or some local con- 
dition of the uterus itself. 

Constitutional Causes. — Among the former are such as produce a dis- 
turbance of the vascular system of the body generally or of the uterine 
vessels in particular. The state of the uterine sinuses, and the slight 
barrier which the thrombi formed in them offer to the escape of blood, 
readily explain the fact of any sudden vascular congestion producing 
hemorrhage. Thus, mental emotions, the sudden assumption of the 
erect posture, any undue exertion, the incautious use of stimulants, a 
loaded condition of the bowels, or sexual intercourse shortly after deliv- 
ery, may act in this way. Mcdintock records the case of a lady in 
whom very profuse hemorrhage occurred on the twelfth day after labor 
when sitting up for the first time. Feeling faint after sucking, the 
nurse gave her some brandy, whereupon a gush of blood ensued, " delug- 
ing all the bedclothes and penetrating through the mattress so as to form 
a pool on the floor." Here the erect position, the exquisite pain caused 
by nursing, and the stimulating drink, all concurred to excite the hemor- 
rhage. In another instance the flooding was traced to excitement pro- 
duced by the sudden return of an old lover on the eighth day after labor. 
Moreau especially dwells on the influence of local congestion produced 
by a loaded condition of the rectum. Constitutional affections produ- 
cing general debility and an impoverished state of the blood probably 
also may have the same effect. Blot specially mentions albuminuria as 
one of these, and Saboia states that in Brazil secondary hemorrhage is 
a common symptom of miasmatic poisoning, and can only be cured by 
change of air and the free use of quinine. 1 

Local Causes. — Local conditions seem, however, to be the more fre- 
quent factors in the production of secondary hemorrhage. These may be 
generally classed under the following heads : 

1. Irregular and inefficient contraction of the uterus. 

2. Clots in the uterine cavity. 

3. Portions of retained placenta or membranes. 

4. Retroflexion of the uterus. 

5. Laceration or inflammatory state of the cervix. 

6. Thrombosis or hematocele of the cervix or vulva. 

7. Inversion of the uterus. 

8. Fibroid tumors or polypus of the uterus. 

The first four of these need only now be considered, the others bring 
described elsewhere. 

Relaxation of, and Clots in,the Uterus. — Relaxation of the uterus and 
distension of its cavity by coagula may give rise to hemorrhage, although 
not so readily as immediately after delivery, lor coagula of considerable 

size are often retained in utero for many day- after labor. The uterus 
will be found larger than it ought to he, and tender on pressure. I '-ually 
the coagula are expelled with severe after-pains; hut this may no1 take 
place, and hemorrhage may ensue several days after delivery. Or there 
may be only a relaxed state of the uterus without retained coagula. 
Bassett relates four cases traced to these causes, and several illustrations 
will be found in McClintock's paper. Portions of retained placenta o* 

1 Saboia, Traite den Accouchement*, \>. *\'>. 



430 LABOR. 

membranes are more frequent causes. The retention may be due to care- 
lessness on the part of the practitioner, especially if he have removed 
the placenta by traction and failed to satisfy himself of its integrity. It 
may, however, often be due to circumstances entirely beyond his control, 
such as adherent placenta, which it is impossible to remove without leav- 
ing portions in utero, or more rarely placenta succenturia. In the latter 
case there is a small supplementary portion of placental tissue developed 
entirely separate from the general mass, and it may remain in utero with- 
out the practitioner having the least suspicion of its existence. Portions 
of the membranes are very apt to be left in utero. It is to prevent this 
that they should be twisted into a rope and extracted very gently after 
expression of the placenta. Hemorrhage from these causes generally 
does not occur until at least a week after delivery, and it may not do so 
until a much longer time has elapsed. In four cases recorded by Mr. 
Bassett it commenced on the tenth, twelfth, fourteenth, and thirty-second 
day. It may come on suddenly and continue, or it may stop, and recur 
frequently at short intervals. In my experience retention of portions 
of the placenta is very common after abortion, when adhesions are more 
generally met with than at term. In addition to the hemorrhage there 
is often a fetid discharge due to decomposition of the retained portion, 
and possibly more or less marked septicemic symptoms, which may aid 
in the diagnosis. The placenta or membranes may simply be lying loose 
as foreign bodies in the uterine cavity, or they may be organically at- 
tached to the uterine walls, when their removal will not be so easily 
effected. 

Retroflexion. — Barnes has especially pointed out the influence of retro- 
flexion of the uterus in producing secondary hemorrhage, 1 which seems 
to act by impeding the circulation at the point of flexion and thus arrest- 
ing the process of involution. 

In every case in which secondary hemorrhage occurs to any extent 
careful investigation into the possible causes of the attack, and an accu- 
rate vaginal examination, are imperatively required. If it be due to 
general and constitutional causes only, we must insist on the most abso- 
lute rest on a hard bed in a cool room and on the absence of all causes 
of excitement. The liquid extract of ergot will be very generally use- 
ful in 3j doses repeated every six hours. McClintock strongly recom- 
mends the tincture of Indian hemp, which may be advantageously com- 
bined with the ergot, in doses of 10 or 15 minims, suspended in muci- 
lage. Astringent vaginal pessaries of matico or perchloride of iron may 
be used. Special attention should be paid to the state of the bowels, 
and if the rectum be loaded it should be emptied by enemata. In more 
chronic cases a mixture of ergot, sulphate of iron, and small doses of sul- 
phate of magnesia will prove very serviceable. This is more likely to be 
effectual when the bleeding is of an atonic and passive character. McClin- 
tock speaks strongly in favor of the application of a blister over the sac- 
rum. When the hemorrhage is excessive more effectual local treatment 
will be required. Cazeaux advises plugging of the vagina, Although 
this cannot be considered so dangerous as immediately after delivery, in- 
asmuch as the uterus is not so likely to dilate above the plug, still it is 

1 Obstetric Operations, p. 492. 



RUPTURE OF THE UTERUS. 431 

certainly not entirely without risk of favoring concealed internal hemor- 
rhage. If it be used at all, a firm abdominal pad should be applied, so 
as to compress the uterus ; and the abdomen should be examined from 
time to time to ensure against the possibility of uterine dilatation. With 
these precautions the plug may prove of real value. In any case of 
really alarming hemorrhage I should be disposed rather to trust to the 
application of styptics to the uterine cavity. The injection of fluid in 
bulk, as after delivery, could not be safely practised, on account of the 
closure of the os and the contraction of the uterus. But there can be no 
objection to swabbing out the uterine cavity with a small piece of sponge 
attached to a handle and saturated in a solution of the perchloride of 
iron. There are few cases which will resist this treatment. 

If we have reason to suspect retained placenta or membranes, or if 
the hemorrhage continue or recur after treatment, a careful exploration 
of the interior of the womb will be essential. On vaginal examination 
we may possibly feel a portion of the placenta protruding through the 
os, which can then be removed without difficulty. If the os be closed, 
it must be dilated with sponge or laminaria tents or by a small-sized 
Barnes's bag, and the uterus can then be thoroughly explored. This 
ought to be done under chloroform, as it cannot be effectually accom- 
plished without introducing the whole hand into the vagina, which 
necessarily causes much pain. If the placenta or membranes be loose 
in the uterine cavity, they may be removed at once, or if they be organic- 
ally attached, they may be carefully picked off. The uterus should at 
the same time, and as long as the os remains patulous, be thoroughly 
washed out with Condy's fluid and water to' diminish the risk of sep- 
ticaemia. 

Retroflexion can readily be detected by vaginal examination and the 
treatment consists in careful reposition with the hand and the application 
of a large-sized Hodge's pessary. 



CHAPTER XVI. 

RUPTURE OF THE UTERUS, ETC. 

Its Fatality. — Rupture of the uterus is one of the most dangerous 
accidents of labor, and until of late years it has been considered almost 
necessarily fatal and beyond the reach of treatment. Fortunately, it is 
not of very frequent occurrence, although the published statistics vary 
so much that it Is by no mean- easy t<> arrive ;it any conclusion on this 
point. The explanation is, no doubt, that many of the table- confound 
partial and comparatively unimportant lacerations of the cervix and 
vagina with rupture of the body and fundus. It isonly in large lying- 
in institutions, where the results of cases are accurately recorded, that 
anything like reliable statistics can be gathered, for in private practice 



432 LABOR. 

the occurrence of so lamentable an accident is likely to remain unpub- 
lished. To show the difference between the figures given by authorities, 
it may be stated that while Burns calculates the proportion to be 1 in 
940 labors, Ingleby fixes it as 1 in 1300 or 1400, Churchill as 1 in 
1331, and Lehmann as 1 in 2433. Dr. Jolly of Paris has published an 
excellent thesis containing much valuable information. 1 He finds that 
out of 782,741 labors, 230 ruptures, excluding those of the vagina or 
cervix, occurred — that is, 1 in 3403. 

Seat of Rupture. — Lacerations may occur in any part of the uterus — 
the fundus, the body, or the cervix. Those of the cervix are compara- 
tively of small consequence, and occur to a slight extent in almost all 
first labors. Only those which involve the supra- vaginal portion are of 
really serious import. Ruptures of the upper part of the uterus are 
much less frequent than of the portion near the cervix — partly, no 
doubt, because the fundus is beyond the reach of the mechanical causes 
to which the accident can, not unfrequently, be traced, and partly because 
the lower third of the organ is apt to be compressed between the pre- 
senting part and the bony pelvis. The site of placental insertion is said 
by Madame La Chapelle to be rarely involved in the rupture, but it 
does not always escape, as numerous recorded cases prove. The most 
frequent seat of rupture is near the junction of the body and neck, either 
anteriorly or posteriorly, opposite the sacrum, or behind the symphysis 
pubis, but it may occur at the sides of the lower segment of the uterus.. 
In some cases the entire cervix has been torn away and separated in the 
form of a ring. 

Rupture may be Partial or Complete.— -The laceration may be partial 
or complete, the latter being the more common. The muscular tissue 
alone may be torn, the peritoneal coat remaining intact ; or the converse 
may occur, and then the peritoneum is often fissured in various direc- 
tions, the muscular coat being unimplicated. The extent of the injury 
is very variable, in some cases being only a slight tear, in others form- 
ing a large aperture, sufficiently extensive to allow the foetus to pass into 
the abdominal cavity. The direction of the laceration is as variable as 
the size, but it is more frequently vertical than transverse or oblique. 
The edges of the tear are irregular and jagged, probably on account of 
the contraction of the muscular fibres, which are frequently softened, 
infiltrated with blood, and even gangrenous. Large quantities of extrav- 
asatecl blood will be found in the peritoneal cavity, such hemorrhage, 
indeed, being one of the most important sources of danger. 

The causes are divided into predisposing and exciting ; and the prog- 
ress of modern research tends more and more to the conclusion that the 
cause which leads to the laceration could only have operated because the 
tissue of the uterus was in a state predisposed to rupture, and that it 
would have had no such effect on a perfectly healthy organ. What 
these predisposing changes are, and how they operate, is y£t far from 
being known, and the subject offers a fruitful field for pathological 
investigation. 

Said to be more Common in Multiparce. — It is generally believed that 
lacerations are more common in multipara? than in primiparse. Tyler 

1 Rupture uterine pendant le Travail, Paris, 1S73. 



RUPTURE OF THE UTERUS. 433 

Smith contended that ruptures are relatively as common in first as in 
subsequent labors, while Bandl l found that only 64 cases out of 546 
ruptures were in primipara?. Statistics are not sufficiently accurate or 
extensive to justify a positive conclusion, -but it is reasonable to suppose 
that the pathological changes presently to be mentioned as predisposing 
to laceration are more likely to be met with in women whose uteri have 
frequently undergone the alteration attendant on repeated pregnancies. 
Age seems to have considerable influence, as a large proportion of eases 
have occurred in women between thirty and forty years of age. 

Alterations in the tissues of the uterus are probably of very great import- 
ance in predisposing to the accident, although our information on this point 
is far from accurate. Among these are morbid states of the muscular 
fibres, the result of blows and contusions during pregnancy ; premature 
fatty degeneration of the muscular tissues — an anticipation, as it were, 
of the normal involution after delivery ; fibroid tumors or malignant 
infiltration of the uterine walls, which either produce a morbid state of 
the tissues or act as an impediment to the expulsion of the foetus. The 
importance of such changes has been specially dwelt on by Murphy in 
this country and by Lehmann in Germany, and it is impossible not to 
concede their probable influence in favoring laceration. However, as 
yet these views are founded more on reasonable hypothesis than on accu- 
rately-observed pathological facts. 

Another and very important class of predisposing causes are those 
which lead to a want of proper proportion between the pelvis and the 
foetus. 

Deformity in Pelvis is a Frequent Cause. — Deformity of the pelvis 
has been very frequently met with in cases in which the uterus has rup- 
tured. Thus, out of 19 cases carefully recorded by Radford, 2 the pelvis 
was contracted in 11, or more than one-half. Radford makes the curious 
observation that ruptures seem more likely to occur when the deformity 
is only slight ; and he explains this by supposing that in slight deformi- 
ties the lower segment of the uterus engages in the brim, and is therefore 
much subjected to compression, while in extreme deformity the os and 
cervix uteri remain above the brim, the body and fundus of the uterus 
hanging down between the thighs of the mother. This explanation is 
reasonable, but the rarity with which ruptured uterus is associated with 
extreme pelvic deformity may rather depend on the infrequency of ad- 
vanced degrees of contraction. 

Views. of Bandl. — Bandl, who has made the most important of mod- 
ern contributions to our knowledge of the subject, point- out that rap- 
ture nearly always begins in the lower segment of the uterus, which 
becomes abnormally stretched and distended when from any cause the 
expulsion of the foetus is delayed. The upper portion of the uterus 
becomes at the same time retracted and much thickened (see Fig. 1 16). 
As the pains continue .the stretching of the lower segment becomes more 
and more marked, until at last its fibres separate and a laceration is 
established. The line of demarcation between the thickened body and 
the distended lower segment, known as the ring of Bandl, can in 
cases be occasionally made out by palpation above the pubes. 

1 Ueber Ruptur der Gebarmutter, Wien, 1815, ■ Obst. TYmu., v<>l. viii. 

28 



•l|e|| 



434 



LAB OB. 



Malpresentation or Undue Size of the Foetus. — Amongst causes of dis- 
proportion depending on the foetus is either malpresentation, in which 
the pains cannot effect expulsion, or undue size of the presenting part. 
In the latter way may be explained the observation that rupture is more 




Illustrating the Dangerous Thinning of the Lower Segment of Uterus, owing to Non-descent of 
Head in a Case of Intra-uterine Hydrocephalus. (After Bandl.) 

frequently met with in the delivery of male than of female children, on 
account, no doubt, of the larger size of the head in the former. The 
influence of intra-uterine hydrocephalus was first prominently pointed 
out by Sir James Simpson, 1 who states that out of 74 cases of intra- 
uterine hydrocephalus, the uterus ruptured in 16. In all such cases of 
disproportion, whether referable to the pelvis or fcetus, rupture is pro- 
duced in a twofold manner — either by the excessive and fruitless uterine 
contractions, which are induced by the efforts of the organ to overcome 
the obstacle, or by the compression of the uterine tissue between the pre- 
senting part and the bony pelvis, leading to inflammation, softening, 
and even gangrene. 

3fechanical Injury. — The proximate cause of rupture may be classed 
under two heads — mechanical injury and excessive uterine contraction. 
Under the former are placed those uncommon cases in which the uterus 
lacerates as the result of some injury in the latter months of pregnancy, 
such as blows, falls, and the like. Not so rare, unfortunately, are lace- 
rations produced by unskilled attempts at delivery on the part of the 
1 Selected Obst. Works, p. 385. 



RUPTURE OF THE UTERUS. 435 

medical attendant, such as by the hand during turning or by the blades 
of the forceps. Many such cases are on record in which the accoucheur 
has used force and violence rather than skill in his attempts to overcome 
an obstacle, That such unhappy results of ignorance are not so uncom- 
mon as they ought to be is proved by the figures of Jolly, who has col- 
lected 71 cases of rupture during podalic version, 37 caused by the for- 
ceps, 10 by the cephalotribe, and 30 during other operations, the precise 
nature of which is not stated. 1 The modus operandi of protracted and 
ineffectual uterine contractions, as a proximate cause of rupture, is suf- 
ficiently evident, and need not be dwelt on. It is necessary to allude, 
however, to the effect of ergot, incautiously administered, as a producing 
cause. There is abundant evidence that the injudicious exhibition of 
this drug has often been followed by laceration of the unduly-stimulated 
uterine fibres. Thus, Trask, talking of the subject, says that Meigs 
had seen three cases, and Bedford four, distinctly traceable to this cause. 
Jolly found that ergot had been administered largely in 33 cases in 
which rupture occurred. 

Premonitory Symptoms. — Some have believed that the impending 
occurrence of rupture could frequently be ascertained by peculiar pre- 
monitory symptoms, such as excessive and acute crampy pains about the 
lower part of the abdomen, due to the compression of part of the uterine 
walls. These are far too indefinite to be relied on, and it is certain that 
the rupture generally takes place without any symptoms that would 
have afforded reasonable grounds for suspicion. 

General Symptoms. — The symptoms are often so distinct and alarm- 
ing as to leave no doubt as to the nature of the case. Not infrequently, 
however, especially if the laceration be partial, they are by no means so 
well marked, and the practitioner may be uncertain as to what has taken 
place. In the former class of cases a sudden excruciating pain is expe- 
rienced in the abdomen, generally during the uterine contractions, 
accompanied by a feeling on the part of the patient of something having 
given way. In some cases this has been accompanied by an audible 
sound, which has been noticed by the bystanders. At the same time 
there is generally a considerable escape of blood from the vagina, and a 
prominent symptom is the sudden cessation of the previously strong 
pains. Alarming general symptoms soon develop, partly due to shock, 
partly to loss of blood, both external and internal. The face exhibits 
the greatest suffering, the skin becomes deadly cold and covered with a 
clammy sweat, and fainting, collapse, rapid feeble pulse, hurried breath- 
ing, vomiting, and all the usual signs of extreme exhaustion quickly 
follow. 

Results of Abdominal and \'<i(jin<tl Examination^. — Abdominal pal- 
pation and vaginal examination both afford characteristic indication- in 
well-marked cases. If the child, as often happens, lias escaped entirely 
or in great part into the abdominal cavity, it may he readily fell 
through the abdominal walls; while in the Cornier case the partially- 
contracted uterus may be found separate from it in the form of a glob- 
ular tumor resembling the uterus after delivery. Per vaginaru it may 
generally be ascertained that the presenting part has suddenly receded 

1 O,,. r/7., ].. 38. 



436 LABOR. 

and can no longer be made out, or some other part of the foetus may be 
found in its place. If the rupture be extensive, it may be appreciable 
on vaginal examination, and sometimes a loop of intestine may be found 
protruding through the tear. Other occasional signs have been 
recorded, such as an emphysematous state of the lower part of the 
abdomen, resulting from the entrance of air into the cellular tissue, or 
the formation of a sanguineous tumor in the hypogastrium or vagina. 
These are too uncommon and too vague to be of much diagnostic value. 
Symptoms are Sometimes Obscure. — Unfortunately, the symptoms are 
by no means always so distinct, and cases occur in which most of the 
reliable indications, such as the sudden cessation of the pains, the exter- 
nal hemorrhage, and the retrocession of the presenting part, may be 
absent. In some cases, indeed, the symptoms have been so obscure that 
the real nature of the case has only been detected after death. It is 
rarely, however, that the occurrence of shock and prostration is not suf- 
ficiently distinct to arouse suspicion, even in the absence of the usual 
marked signs. In not a few cases distinct and regular contractions have 
gone on after laceration, and the child has even been born in the usual 
way. Of course in such a case mistake is very possible. So curious a 
circumstance is difficult of explanation. The most probable way of 
accounting for it is that the laceration has not implicated the fundus of 
the uterus, which contracted sufficiently energetically to expel the foetus. 
Hence it will be seen that the symptoms are occasionally obscure, and 
the practitioner must be careful not to overlook the occurrence of so seri- 
ous an accident because of the absence of the usual and characteristic 
symptoms. 

Prognosis. — The prognosis is necessarily of the gravest possible cha- 
racter, but modern views as to treatment perhaps justify us in saying 
that it is not so absolutely hopeless as has been generally taught in our 
obstetric works. 

To the Mother. — When we reflect on what has occurred — the profound 
nervous shock; the profuse hemorrhage, both external, and especially 
into the peritoneal cavity, where the blood coagulates and forms a for- 
eign body ; the passage of the uterine contents into the abdomen, with 
the inevitable result of inflammation and its consequences if the patient 
survive the primary shock, — the enormous fatality need cause no sur- 
prise. Jolly has found that out of 580 cases 100 recovered — that is, in 
the proportion of 1 out of 6. This is a far more favorable result than 
w r e are generally led to anticipate ; and as many of the recoveries hap- 
pened in apparently the most desperate and unfavorable cases, we should 
learn the lesson that we need not abandon all hope, and should at least 
endeavor to rescue the patient from the terrible dangers to which she is 
exposed. 

To the Child. — As regards the child, the prognosis is almost necessarily 
fatal ; and, indeed, the cessation of the foetal heart-sounds has been 
pointed out by McClintock as a sign of rupture in doubtful cases. The 
shock, the profuse hemorrhage, and the time that must necessarily elapse 
before the delivery of the child are of themselves quite sufficient to 
explain the fact that the foetus is almost always dead. 

Treatment. — From what has been said of the impossibility of fore- 



RUPTURE OF THE UTERUS. 437 

telling the occurrence of rupture, it must follow that no reliable prophy- 
lactic treatment can be adopted beyond that which is a matter of general 
obstetric principle — viz. timely interference when the uterine contractions 
seem incapable of overcoming an obstacle to delivery, either on the part 
of the pelvis or foetus. 

Indications after Rupture has Taken Place. — After rupture the main 
indications are to effect the removal of the child and the placenta, to 
rally the patient from the effects of the shock, and, if she survives so 
long, to combat the subsequent inflammation and its consequences. By 
far the most important point to decide is the best means to be adopted 
for the removal of the child ; for it is admitted by all that the hopeless 
expectancy that was recommended by the older accoucheurs — or, in other 
words, allowing the patient to die without making any effort to save 
her — is quite inadmissible. If the foetus be entirely within the uterine 
cavity, no doubt the proper course to pursue is to deliver at once per vias 
naturales, either by turning, by forceps, or by cephalotripsy. If any 
part other than the head present, turning will be best, great care being 
taken to avoid further increase of the laceration. If the head be in the 
cavity or at the brim of the pelvis, and within easy reach of the forceps, 
it may be cautiously applied, the child being steadied by abdominal 
pressure so as to facilitate its application. If there be, as is often the 
case, some slight amount of pelvic contraction, it may be preferable to 
perforate and apply the cephalotribe, so as to avoid any forcible attempts 
at extraction, which might unduly exhaust the already prostrate patient 
and turn the scale against her. This will be the more allowable since 
the child is, as we have seen, almost always dead, and we might readily 
ascertain if it be so by auscultation. 

Removal of the Placenta. — After delivery extreme care must be taken 
in removing the placenta, and for this it will be necessary to introduce 
the hand. The placenta will generally be in the uterus, for if the rent 
be not large enough for the child to pass through, it may be inferred that 
the placenta will not have done so either. If it has escaped from the 
uterus, very gentle traction on the cord may bring it within reach of the 
hand, and so the passage of the hand through the tear to search for it 
will be avoided. 

Treatment when the Foetus has Escaped out of the Uterus. — There can 
be but little doubt that in the cases indicated such is the proper treat- 
ment and that which affords the mother the best chance. I Fnfortunately, 
the cases in which the child remains entirely in utero are comparatively 
uncommon, and generally it will have escaped into I lie abdomen, along 
with much extravasated blood. The usual plan of treatment recom- 
mended under such circumstances is to puss the hand through the 
fissure (some have even recommended that it should be enlarged by 
incision if necessary), to seize the feet of the II. 'ins, to drag it back 
through the torn uterus, and then to reintroduce the hand to search for 
and remove the placenta, [magine what occurs during the process! 
The hand gropes blindly among the abdominal viscera, the furrihle, 
dragging back of the foetus necessarily tears tin- uterus more and more, 
and, above all, the extravasated blood remains as. a foreign body in the 
peritoneal cavity, and necessarily gives rise to the mosi serious conse- 



438 



LABOR. 



quences. It is surely hardly a matter of surprise that there is scarcely 
a single case on record of recovery after this procedure. 

Reasons why Gastrotomy affords a Better Chance of Success. — Of late 
years a strong feeling has existed that whenever the child has entirely 
or in great part escaped into the abdominal cavity the operation of gas- 
trotomy aifords the mother a far better chance of recovery ; and it has 
now been performed in many cases with the most encouraging results. 
It is easy to see why the prospects of success are greater. The uterus 
being already torn and the peritoneum opened, the only additional dan- 
ger is the incision of the abdominal parietes, which gives us the oppor- 
tunity of sponging out the peritoneal cavity, as in ovariotomy, and of 
removing all the extravasated blood, the retention of which so seriously 
adds to the dangers of the case. Another advantage is that, if the 
patient be excessively prostrate, the operation may be delayed until she 
has somewhat rallied from the effects of the shock, whereas delivery by 
the feet is generally resorted to as soon as the rupture is recognized and 
when the patient is in the worst possible condition for interference of any 
kind. 

Comparative Results of Various Methods of Treatment. — Jolly has 
carefully tabulated the results of the various methods of treatment, and, 
making every allowance for the unavoidable errors of statistics, it seems 
beyond all question that the results of gastrotomy are so greatly superior 
to those of other plans that I think its adoption may fairly be laid down 
as a rule whenever the foetus is no longer within the uterine cavity : 

Comparative Kesults of Various Methods of Treatment after Rupture 

of Uterus. 



Treatment- 



Expectation 

Extraction per vias naturales 
Gastrotomy 



No. of 

Cases. 


Deaths. 


144 

382 
38 


142 

310 

12 



Recoveries. 



2 
72 
26 



Per cent, of 
Recoveries. 



1.45 
19 

68.4 



Of course this table will not justify the conclusion that 68 per cent, 
of the cases of ruptured uterus in which gastrotomy is performed will 
recover ; but it may fairly be taken as proving that the chances of 
recovery are at least three or four times as great as when the more usual 
practice is adopted. 

[American Puerperal Laparotomies. — After a search of several years 
I have thus far collected 43 cases in the United States, with 21 women 
and 2 children saved. One mother and child were saved by an imme- 
diate operation with a pocket-knife in 1869. I presume that a general 
record of American operations, published and unpublished, would show 
a saving of nearly 50 per cent., which is much lower than that claimed 
by Trask and Jolly, collected from published reports. Take Trask's 
foreign cases, 20, and our own 43, and we have, native and foreign, 63, 
with 37 recoveries and 26 deaths. I look upon our own statistics as 
much more reliable, because many of the unpublished cases were searched 
out by correspondence. — Ed.] 



RUPTURE OF THE UTERUS. 439 

Lacerations of the Cervix. — Lacerations of the cervix are of very 
common occurrence. Occasionally, after delivery, they may cause hem- 
orrhage when the uterus itself is firmly contracted, or secondarv hemor- 
rhage during the puerperal month. As a rule, they are not recognized, 
and it is only of late years, chiefly owing to the labors of Emmet, that 
this important influence in producing various chronic forms of uterine 
disease has been realized. In the large majority of cases the lacerations 
are lateral, either on one or both sides of the cervix. If they give rise 
to hemorrhages, the local application of styptics is probably the best 
resource. Whether it is advisable to treat severe forms by the imme- 
diate application of silver sutures, as recommended by Pallen, 1 is a sub- 
ject as yet too little understood to justify the expression of an opinion. 

Necessity of Care in Performing the Operation. — It is perhaps needless 
to say that the operation must be performed with the same minute care 
that has raised ovariotomy to its present pitch of perfection, and that 
especial attention should be paid to the sponging out of the peritoneum, 
and the removal of foreign matters. 

Recapitulation. — To recapitulate, I think what has been said justifies 
the following rules of treatment after rupture : 

1. If the head or presenting part be above the brim and the foetus 
still in utero — forceps, turning, or cephalotripsy, according to circum- 
stances. 

2. If the head be in the pelvic cavity — forceps or cephalotripsy. 

3. If the foetus have wholly or in great part escaped into the abdomi- 
nal cavity — gastrotomy. 

Subsequent Treatment. — As to the subsequent treatment little need be 
said, since in this we must be guided by general principles. The chief 
indication will be to remove shock and rally the patient by stimulants, 
etc., and to combat secondary results by opiates and other appropriate 
remedies. 

Laceration* of the vagina occasionally take place, and in the great 
majority of cases they are produced by instruments, either from a want 
of care in their introduction or from undue stretching of the vagina] 
walls during extraction with the forceps. Slight vaginal lacerations arc 
probably much more common after forceps delivery than is generally 
believed to be the case. As a rule, they are productive of no permanent 
injury, although it must not be forgotten that every breach of continuity 
increases the risk of subsequent septic absorption. When the laceration 
is sufficiently deep to tear through the recto-vagina] septum <>r the 
anterior vaginal wall, the passage of the urine or feces is apt to prevent 
its edges uniting; then that most distressing condition, recto-vaginal or 
vesico-vaginal fistula, is established. 

Fistula? are Seldom ('(/used by Mechanical Injur//. — It rausl not be 
supposed that fistula} are often the result <>f injury during operative 
interference. That is a common but very erroneous opinion both among 
the profession and the public. In the vast majority of cases the fistu- 
lous opening is the consequence of a slough resulting from inflammation, 
produced by long-continued pressure of the vaginal walls between the 
child's head and the bony pelvis in cases in which the second stage has 



440 LABOR. 

been allowed to go on too long. In most of these cases instruments 
were doubtless eventually used, and they get the blame of the accident ; 
whereas the fault lay, not in their being employed, but rather in their 
not having been used soon enough to prevent the contusion and inflam- 
mation which ended in sloughing. 

Proof of this Statement. — When vesico-vaginal fistula? are the result 
of lacerations during labor, the urine must escape at once, but this is 
rarely the case. In the large majority of cases the urine does not pass 
per vaginam until more than a week after delivery, showing that a lapse 
of time is necessary for inflammatory action to lead to sloughing. In 
order to throw some light on these points, on which very erroneous 
views have been held, I have carefully examined the histories, from 
various sources, of 63 cases of vesico-vaginal fistula. 

1st. In 20 no instruments were employed. Of these, there were in 
labor — 

Under 24 hours 2 

From 24 to 48 hours 8 l 

" 48 to 70 " 2 

" 70 to 80 " 7 

" 80 hours and upward • 1 

20 

Therefore, out of these 20 cases, one-half were certainly more than 48 
hours in labor, and 6 of the remaining 10 were probably so also. In 
only 1 of them is the urine stated to have escaped per vaginam immedi- 
ately after delivery. In 7 it is said to have done so within a week, and 
in the remainder after the seventh day. 

2d. In 34 cases instruments were used, but there is no evidence of 
their having produced the accident. Of these, there were in labor — 

Under 24 hours 2 

From 24 to 48 hours 8 

" 48 to 72 " 10 

" 72 hours and upward . - 14 

34 

The urine escaped within 24 hours in 2 cases only, within a week in 16, 
and after the seventh day in 15. So that here, again, we have the his- 
tory of unduly-protracted delivery, 24 out of the 34 having been cer- 
tainly more than 48 hours in labor. 

3d. In 9 cases the histories show that the production of the fistula 
may fairly be ascribed to the unskilled use of instruments. Of these, 
there were in labor — 

Under 24 hours .7 

From 24 to 48 hours l 

" 48 to 72 " 1 

9 

The urine escaped at once in 7 cases, and in the remaining 2 after the 

seventh day. 

1 But of these, in 7 no precise time is stated. 6 of them are marked very tedious, 
therefore they probably exceeded the limit. 



RUPTURE OF THE UTERUS. 441 

These statistics seem to me to prove, in the clearest manner, that in 
the large majority of cases this unhappy accident may be directly traced 
to the bad practice of allowing labor to drag on many hours in the sec- 
ond stage without assistance, and not to premature instrumental interfe- 
rence. This question has recently been elaborately studied by Emmet, 
who gives numerous statistical tables which fully corroborate these views. 
His conclusion, the result of much practical experience of vesico-vaginal 
fistulse, is worthy of being quoted. " I do not hesitate," he says, " to 
make the statement that I have never met with a case of vesico-vaginal 
fistula which without doubt could be shown to have resulted from 
instrumental delivery. On the contrary, the entire weight of evidence 
is conclusive in showing that the injury is a consequence of delay in 
delivery." l 

Treatment. — As to the treatment of vaginal laceration, little can be 
said. In the slighter cases vaginal injections of diluted Condy's fluid 
will be useful to lessen the risk of septic absorption ; and the graver, 
when vesico-vaginal or recto-vaginal fistulse have actually formed, are 
not within the domain of the obstetrician, but must be treated surgically 
at some future date. 

[The Rational Treatment of Rupture of the Uterus. — The three rules 
given on page 439 are those found in obstetrical works of high author- 
ity, but are not based upon the teachings of abdominal surgery as shown 
by the results of operations recorded within a few years. Reasoning 
from analogy and the fearful mortality of cases delivered per vias nat- 
urales after uterine rupture, we are forced to the conclusion that some- 
thing more is needed than the delivery of the woman and the removal 
of the placenta if we hqpe to reduce the proportion of deaths, which is 
very great except after laparotomy — a method of delivery capable of 
saving nearly 50 per cent. There is no objection to delivering the foetus 
by the natural channel, provided it can be readily done ; but we have 
very little reason to anticipate a favorable result if we rest our efforts 
here. Children entirely escaped into the abdominal cavity have been 
drawn back through the rent and delivered by the vagina, and the 
women have recovered. In one well-authenticated case the woman was 
thus saved in our own country on four occasions. But we arc not to 
expect such results, as a fatal issue is far more frequent than a recovery 
under such circumstances. Our object should be to save the life of the 
mother and, if at all possible, that of the foetus; and all our efforts 
should be directed to this cud. We may console ourselves with having 
delivered the woman prior to her death, but to prevent this fatal issue 
should be our chief aim. The general impression among ovariotomists 
is, that blood is not an innocent fluid in the abdominal cavity ; and the 
remarkable results of the operations of Dr. Keith of Edinburgh are 
attributed to the care he exercises in preventing the secondary escape 
of blood into the abdominal cavity. Dr. Ludwig Winckel ofMiilheim, 
Germany, who performed the ( Cesarean operation L 3 times and laparo- 
tomy after rupture of the uterus I times, was of the impression that the 
liquor ainnii was innocuous if only a short time in contact with the 
peritoneum; and the same may be said of blood, ovarian fluid, parova- 
1 The Principle* and Practice of Oyncecoloyy, p. 669. 



442 LABOR. 

rian fluid, and, to some degree, also of urine. Rupture of the bladder is 
now cured by sewing up the rent and carefully cleansing the abdominal 
cavity of blood and urine. But these fluids are all capable of setting up 
peritonitis, and blood by its decomposition is particularly apt to give 
rise to septic poisoning : then why let it remain in the abdominal cavity 
in cases of ruptured uterus ? If it is important to cleanse this cavity 
from blood and ovarian fluid in ovariotomy, and from blood and amni- 
otic fluid after the Cesarean section, then why should we be content 
with delivering the foetus in cases of rupture of the uterus, when we 
know that the peritoneal cavity still contains a compound fluid which 
may destroy the woman if not removed and the parts cleansed ? We 
have also an additional risk in the fact that the uterine rupture may 
gape and allow the lochia to escape into the peritoneal cavity, thus pro- 
viding another element for septic poisoning. I am, then, fully per- 
suaded that in all cases of rupture, where it is evident that blood and 
liquor amnii have escaped into the abdominal cavity, we ought to open 
the abdomen, cleanse out the cavity, and close the rent by deep-seated 
and superficial sutures of silver wire or carbolized pure silk. In cer- 
vico-vaginal rupture the closure of the rent may not be so important in 
the sense of safety to the woman, as there is generally a natural drain- 
age into the vagina ; neither is laparotomy itself so imperatively 
demanded as in cases where the fundus or body of the uterus is rent. 
But it becomes important to close the rent cervix in view of future 
trouble from ectropium and erosion. As in the Csesarean operation, 
promptness of action is all important if we hope to save the patient. I 
know that these views upon the treatment of ruptured uterus are in 
advance of those held by British obstetrical writers, but they are cer- 
tainly logical deductions from the experience of such operators as Dr. 
Keith, Mr. Lawson Tait, and others, and from the well-known results 
of promptly-performed laparotomies in rupture accidents in the United 
States. The removal of the uterus after rupture has as yet only added 
to the risk, and I do not believe we are justified in resorting to it where 
there is no pelvic obstruction. — Ed.] 



CHAPTER XVII. 

INVEKSION OF THE UTEKUS. 

Its Formidable Character. — Inversion of the uterus shortly after the 
birth of the child is one of the most formidable accidents of parturition, 
leading to symptoms of the greatest urgency, .not rarely proving fatal, 
and requiring prompt and skilful treatment. Hence it has obtained an 
unusual amount of attention, and there are few obstetric subjects which 
have been more carefully studied. 

An Accident of Great Rarity. — Fortunately, the accident is of great 



INVERSION OF THE UTERUS. 



443 



rarity. It was only observed once in upward of 190,800 deliveries at 
the Rotunda Hospital since its foundation in 1745, and many prac- 
titioners Lave conducted large midwifery practices for a lifetime without 
ever having witnessed a case. It is none the less needful, however, that 
we should be thoroughly acquainted with its natural history and with 
the best means of dealing with the emergency when it arises. 

Division into Acute and Chronic Forms. — Inversion of the uterus 
may be met with in the acute or chronic form ; that is to say, it may 
come under observation either immediately or shortly after its occurrence, 
or not until after a considerable lapse of time, when the involution fol- 
lowing pregnancy has been completed. The latter falls more properly 
under the province of the gynaecologist, and involves the consideration 
of many points that would be out of place in a work on obstetrics. Here, 
therefore, the acute form alone is considered. 

Description of Inversion. — Inversion consists essentially in the en- 
larged and empty uterus being turned inside out, either partially or 
entirely ; and this may occur in various de- 
grees, three of which are usually described 
and are practically useful to bear in mind. 
In the first and slightest degree there is 
merely a cup-shaped depression of the fun- 
dus (Fig. 147) ; in the second the depres- 
sion is greater, so that the inverted portion 
forms an intro-susception, as it were, and 
projects downward through the os in the 
form of a round ball, not unlike the body 
of a polypus, for which, indeed, a careless 
observer might mistake it ; and, thirdly, 
there is the complete variety, in which the 
whole organ is turned inside out, and may 
even project beyond the vulva. 

Its Symptoms. — The symptoms are gen- 



7 characteristic, although wiien 




Parti'il Inversion of i he Fundus. 

(From h preparation in the Museum "t 

Guy's Hospital.) 



the amount of inversion is small they may 
entirely escape observation. They are 
chiefly those of profound nervous shock 
— viz. fainting, small, rapid, and feeble 
pulse, possibly convulsions and vomiting, 
and a cold clammy skin. Occasionally severe abdominal pain and cramp 
and bearing-down are felt. Hemorrhage is a frequent accompaniment, 
sometime- to a very alarming extent, especially if the placenta be par- 
tially or entirely detached. The loss of blood depends to a great extent 
on the condition of the uterine parietes. If there be much contraction 
on the part that is not inverted, the intro-suscepted part may !><■ suf- 
ficiently compressed to prevent any great loss. II' the entire organ be 
in a state of relaxation, the loss may be excessive. 

Results qf Physical Examination. — The occurrence of such symptoms 
shortly after delivery would of necessity lead to an accurate examination, 
when the nature of the case may 1><' at once ascertained. On passing 
the finger into the vagina we either find the entire uterus forming ;i glob- 



444 LABOR. 

ular mass, to which the placenta is often attached, or, if the inversion 
be incomplete, the vagina is occupied by a firm, round, and tender swell- 
ing which can be traced upward through the os uteri. The hand placed 
on the abdomen will detect the absence of the round ball of the con- 
tracted uterus, and bi-manual examination may even enable us to feel 
the cup-shaped depression at the site of inversion. 

Differential Diagnosis. — When such signs are observed immediately 
after delivery mistake is hardly possible. Numerous instances, however, 
are recorded in which the existence of inversion was not immediately 
detected, and the tumor formed by it only observed after the lapse of 
several days, or even longer, when the general symptoms led to vaginal 
examination. It is probable that in such cases a partial inversion had 
taken place shortly after delivery, which as time elapsed became grad- 
ally converted into the more complete variety. In a case of this kind, 
as in a chronic inversion, some care is necessary to distinguish the inver- 
sion from a uterine polypus, which it closely resembles. The cautious 
insertion of the sound will render the diagnosis certain, since its passage 
is soon arrested in inversion, while if the tumor be polypoid it readily 
passes in as far as the fundus. 

Manner in which Inversion is Produced. — The mechanism by which 
inversion is produced is well worthy of study, and has given rise to 
much difference of opinion. 

Occasionally Produced by Accidental Mechanical Causes. — A very 
general theory is that it is caused in many cases by mismanagement of 
the third stage of labor, either by traction on the cord, the placenta 
being still adherent, or by improperly-applied pressure on the fundus ; 
the result of both these errors being a cup-shaped depression of the fun- 
dus, which is subsequently converted into a more complete variety of 
inversion. That such causes may suffice to start the inversion cannot 
be doubted, but it is probable that their frequency has been much exag- 
gerated. Still, there are numerous recorded cases in which the com- 
mencement of the inversion can be traced to them. Improperly-applied 
pressure (as when the whole body of the uterus is not grasped in the 
hollow of the hand, but when a monthly nurse or other uninstructed 
person presses on the lower part of the abdomen so as simply to push 
down the uterus en masse) is often mentioned in histories of the accident. 
Thus, in the Edinburgh Medical Journal for June, 1848, a case is related 
in which the patient would not have a medical man, but was attended 
by a midwife, who after the birth of the child pulled on the cord, while 
the patient herself clasped her hands and pushed down her abdomen, at 
the same time straining forcibly, when the uterus became inverted and 
the patient died of hemorrhage before assistance could be procured. 
Here both of the mechanical causes mentioned were in operation. In 
several cases it is mentioned that the accident occurred while the nurse 
was compressing the abdomen. That the accident is practically impos- 
sible when firm and equable contraction has taken place cannot be ques- 
tioned. Hence it is of paramount importance that the practitioner should 
himself carefully attend to the conduct of the third stage of labor. 

Often Occurs Spontaneously. — In a large proportion of cases no 
mechanical causes can be traced, and the occurrence of spontaneous 



INVERSION OF THE UTERUS. 445 

inversion must be admitted. There are various theories held as to 
how this occurs. Partial and irregular contraction of the uterus is 
generally admitted to be an important factor in its production ; but it 
is still a matter of dispute whether the inversion is produced mainly by 
an active contraction of the fundus and body of the uterus, the lower 
portion and cervix being in a state of relaxation, or whether the precise 
reverse of this exists, the fundus being relaxed and in a state of quasi- 
paralysis, while the cervix and lower portion of the uterus are irregu- 
larly contracted. The former is the view maintained by Radford and 
Tyler Smith, while the latter is upheld by Matthews Duncan. 

Ecidence in Favor of Duncan's Theory. — There are good clinical 
reasons for believing that Duncan's view more nearly corresponds with 
the true facts of the case ; for if the fundus and body of the uterus be 
really in a state of active contraction while the cervix is relaxed, we 
have, as Duncan points out, the very condition which is normal and 
desirable after delivery, and that which we do our best to produce. If, 
however, the opposite condition exist and the fundus be relaxed, while 
the lower portion is spasmodically contracted, a state exists closely allied 
to the so-called hour-glass contraction. Supposing now any cause pro- 
duces a partial depression of the fundus, it is easy to understand how it 
may be grasped by the contracted portion and carried more and more 
down, in the manner of an intro-susception, until complete inversion 
results. That such partial paralysis of the uterine Avails often exists, 
especially about the placental site, was long ago pointed out by Roki- 
tansky and other pathologists. This theory supposes the original partial 
depression and relaxation of the fundus. How this is often produced 
by mismanagement of the third stage has already been pointed out ; but, 
even in the absence of such causes, it may result from strong bearing- 
down efforts on the part of the patient, or, as Duncan holds, from the 
absence of the retentive power of the abdomen. Indeed, the incompati- 
bility of an actively-contracted state of the fundus with the partial 
depression which is essential, according to both views, for the produc- 
tion of inversion, is the strongest argument in favor of Duncan's theory. 

Taylor's Theory. — A totally different view has more recently been 
sustained by Dr. Taylor of New York, who maintains that "spontane- 
ous active inversion of the uterus rests upon prolonged natural and ener- 
getic action of the body and fundus : the cervix, the lower part, yielding 
first, is thus rolled out or everted or doubled up, as there is no obstruc- 
tion from the contractility of the cervix, which is at rest or functionally 
paralyzed ; the body is gradually, sometimes instantaneously, forced lower ' 
and lower, or inverted." 1 That partial inversion may commence at the 
cervix was pointed out by Duncan in his paper, who depicts it in the 
accompanying diagram (Fig. 148), and states it to be of not unfrequenl 
occurrence. It is not impossible that occasionally such a state of things 
should be carried on to complete inversion. Bui there are serious objec- 
tions to the acceptance of Dr. Taylor's view that such is the principal 
cause of inversion, since the process above described wonld be of neces- 
sity a slow and Long-continued one, whereas nothing is more certain 
than that inversion is generally sudden and accompanied by acute symp 

1 New York Med, Journ., L872 



446 



LAB OB. 



Fig. 148. 




Illustrating the Commencement 

of Inversion at the Cervix. 

(After Duncan.) 



toms of shock, and is often attended by severe hemorrhage, which could 
not occur when such excessive contraction was taking place. 

Treatment. — The treatment of inversion consists in restoring the organ 
to its natural condition as soon as possible. Every moment's delay only 

serves to render restoration more difficult, 
as the inverted portion becomes swollen and 
strangulated ; whereas if the attempt at repo- 
sition be made immediately there is generally 
comparatively little difficulty in effecting it. 
Therefore it is of the utmost importance that 
no time should be lost and that we should not 
overlook a partial or incomplete inversion. 
Hence the occurrence of any unusual shock, 
pain, or hemorrhage after delivery without 
any readily-ascertained cause should always 
lead to a careful vaginal examination. A 
want of attention to this rule has too often 
resulted in the existence of partial inversion 
being: overlooked until its reduction was found 
to be difficult or impossible. 

Mode of Attempting Reduction. — In at- 
tempting to reduce a recent inversion the 
inverted portion of the uterus should be 
grasped in the hollow of the hand and 
pushed gently and firmly upward into its natural position, great care 
being taken to apply the pressure in the proper axis of the pelvis, 
and to use counter-pressure, by the left hand, on the abdominal 
walls. Barnes lays stress on the importance of directing the pressure 
toward one side, so as to avoid the promontory of the sacrum. The 
common plan of endeavoring to' push back the fundus first has been 
well shown by McClintock l to have the disadvantage of increasing 
the bulk of the mass that has to be reduced ; and he advises that while 
the fundus is lessened in size by compression we should at the same 
time endeavor to push up first the part that was less inverted — that is 
to say, the portion nearest the os uteri. Should this be found impossi- 
ble, some assistance may be derived from the manoeuvre, recommended 
by Merriman and others, of first endeavoring to push up one side or 
wall of the uterus, and then the other, alternating the upward pressure 
from one side to the other as we advance. It often happens, as the 
hand is thus applied, that the uterus somewhat suddenly reinverts itself, 
sometimes with an audible noise, much as an india-rubber bottle would 
do under similar circumstances. When reposition has taken place, the 
hand should be kept for some time in the uterine cavity to excite tonic 
contraction ; or Barnes's suggestion of injecting a weak solution of per- 
chloride of iron may be adopted, so as to constrict the uterine walls and 
prevent a recurrence of the accident. 

It is hardly necessary to point out how much these manoeuvres will 
be facilitated by placing the patient fully under the influence of an 
anaesthetic. 

1 Diseases of Women, p. 79. 



INVERSION OF THE UTERUS. 447 

Management of the Placenta. — There has been much difference of 
opinion as to the management of the placenta in cases in which it is 
still attached when inversion occurs. Should we remove it before 
attempting reposition, or should Ave first endeavor to reinvert the 
organ and subsequently remove the placenta ? The removal of the 
placenta certainly much diminishes the bulk of the inverted portion, 
and therefore renders reposition easier. On the other hand, if there 
be much hemorrhage, as is so frequently the case, the removal of the 
placenta may materially increase the loss of blood. For this reason 
most authorities recommend that an endeavor should be made at reduc- 
tion before peeling off the after-birth. But if any delay or difficulty be 
experienced from the increased bulk, no time should be lost, and it is in 
every way better to remove the placenta and endeavor to reinvert the 
organ as soon as possible. 

Management of Cases Detected some time after Delivery. — Supposing 
we met with a case in which the existence of inversion has been over- 
looked for days, or even for a week or two, the same procedure must be 
adopted ; but the difficulties are much greater, and the longer the delay 
the greater they are likely to be. Even now, however, a well-conducted 
attempt at taxis is likely to succeed. Should it fail, we must endeavor 
to overcome the difficulty by continuous pressure applied by means of 
caoutchouc bags distended with water and left in the vagina. It is 
rarely that this will fail in a comparatively recent case, and such only 
are now under consideration. It is likely that by pressure applied in 
this way for twenty- four or forty-eight hours, and then followed by 
taxis, any case detected before the involution of the uterus is com- 
pleted may be successfully treated. 

[Spontaneous Reposition of the Inverted Uterus. — After all attempts 
have failed to replace an inverted uterus, already too much contra* led 
to yield to the pressure employed, Nature sometimes accomplishes the 
work herself, as proved beyond question from quite a number of well- 
established cases, several of which belong to our own country. A few 
years ago I saw one of the most remarkable on record. A woman of 
29, mother of three children, miscarried at six and a half months from 
lifting. From the time of her delivery she was subject to weepings of 
blood, and at times to more or less severe hemorrhages, one of the last 
of which nearly proved fatal. This condition of disease had lasted 
three years, when Dr. Walter F. At lee was called in to relieve her in her 
worst hemorrhagic attack, and found her uterus inverted, and a nodular 
growth upon the fundus which gave out an offensive odor. Thinking 
the disease possibly malignant, and believing, in any event, that to save 
the woman he would be obliged to remove the uterus, he called a con- 
sultation and prepared for the operation ; but when the patient was 
etherized, placed in the knee-elbow position, and SimsV speculum intro- 
duced, behold, there was nothing to be seen in the vagina but a soft 
dilated cervix, the uterus having been replaced by atmospheric pressure, 
aided perhaps by traction on the uterine attachments within. When 
explored, the uterus was found to be very sofl and thin, and to contain 
Some hard nodular masses, which on removal proved to be portions of 
an adherent placenta. The hemorrhage ceased upon the reposition and 



448 LABOR. 

cleaning out of the uterus, and the patient made a good recovery. She 
has been again pregnant. 

This woman was anaemic to a marked degree, and her abdominal walls 
so thin that a finger in the uterus could readily be felt above the pubes. 
There is not the slightest doubt about the inversion, which was proved 
to exist a short time before the change of posture by Prof. Agnew, who 
made a finger in the rectum meet another above the pubes, and there was 
no fundus between them. 

Two 1 cases are upon record where reposition was the result of falls, 
one at eight months and the other after as many years. Drs. Mcehring, 
C. D. Meigs, H. L. Hodge, and Warrington of this city failed to replace 
a uterus, and the woman again became pregnant in about six years, abort- 
ing with a three months' foetus under the care of Dr. Warrington. Dr. 
Meigs saw a second case with Dr. Levis, in which there was violent 
flooding followed by hemorrhages, which gradually declined. After her 
return from a journey West she became pregnant and bore a child. Dr. 
John L. Atlee of Lancaster failed to replace the uterus of a woman, but 
she recovered spontaneously and bore a child a year afterward. 2 Dr. 
Johnson F. Hatch of Kent, Connecticut, reported a case in a letter to 
Dr. C. D. Meigs in which inversion occurred spontaneously fourteen or 
fifteen hours after labor. After being under the care of several physi- 
cians, she had, at the end of eighteen months, two severe hemorrhagic 
attacks, after which she improved, and finally, at the end of two years 
and nine months, bore a child of 9 pounds and 6 ounces. 

In all cases spontaneous reposition appears to result from a softening 
and thinning of the uterine walls as the result of anaemia brought on by 
hemorrhages. This was particularly noticed by Boivin and Duges in 
autopsies of women dying of repeated hemorrhages. — Ed.] 

[ a See Dailliez, Essai sur le Renversement de la Matrice, Paris, 1805, pp. 105-107.] 
[ 2 Meigs's Obstetrics, 1852, Philada., p. 608.] 



PART IV. 

OBSTETRIC OPERATIONS. 



CHAPTER I. 

INDUCTION OF PEEMATUEE LABOE. 

History of the Operation. — The first of the obstetric operations we 
have to consider is the induction of premature labor — an operation which, 
like the use of forceps, was first suggested and practised in this country, 
and the recognition of which, as a legitimate procedure, we also chiefly owe 
to the labor of our fellow-countrymen, in spite of much opposition both at 
home and abroad. It is not known with certainty to whom we owe the 
original suggestion, but we are told by Denman that in the year 1756 there 
was a consultation of the most eminent physicians at that time in Lon- 
don to consider the advantages which might be expected from the opera- 
tion. The proposal met with formal approval, and was shortly after car- 
ried into practice by Dr. Macaulay, the patient being the wife of a linen- 
draper in the Strand. From that time it has flourished in Great Britain, 
the sphere of its application has been largely increased, and it has been 
the means of saving many mothers and children who would otherwise, 
in all probability, have perished. On the Continent it was long before 
the operation was sanctioned or practised. Although recommended by 
some of the most eminent German practitioners, it was not actually per- 
formed until the year 1804. In France the opposition was long con- 
tinued and bitter. Many of the leading teachers strongly denounced it, 
and the Academy of Medicine formally discountenanced it so late as the 
year 1827. Tke objections were chiefly based on religious grounds, but 
partly, no doubt, on mistaken notions as to the object proposed to be 
gained. Although frequently discussed, the operation was never actually 
carried into practice until the year 1831, when Stoltz performed it with 
success. Since that time opposition has greatly ceased, and it is now 
employed and highly recommended by the most distinguished obstetri- 
cians of the French schools. 

Objects of the Operation. — In inducing premature labor we propose to 
avoid or lessen the risk to which, in certain cases, the mother is exposed 
by delivery at term, or to save the life of the child, which might other- 
wise he endangered. Hence the operation may he indicated either on 
account of the mother alone or of the child alone, or, as not anfrequently 
happens, of both together. 

Defective Proportion between the Child <ni<t Pelvis flic most Frequent 

29 449 



450 OBSTETRIC OPERATIONS. 

Indication. — In by far the largest number of cases the operation is per- 
formed on account of defective proportion between the child and the 
maternal passages, due to some abnormal condition on the part of the 
mother. This want of proportion may depend on the presence of tumors, 
either of the uterus or growing from the pelvis. But most frequently 
it arises from deformity of the pelvis (p. 398), and it is needless to repeat 
what has been said on that point. I shall therefore only briefly refer 
to a few more uncommon causes which occasionally necessitate its per- 
formance. 

Habitually Large Size of the Foetal Head. — One of these is an habitu- 
ally large or over-flrmly ossified fcetal head. Should we meet with a 
case in which the labors are always extremely difficult and the head 
apparently of unusual size, although there is no apparent want of space 
in the pelvis, the induction of labor would be perfectly justifiable, and 
in all probability would accomplish the desired object. In such cases 
the full period of delivery would require to be anticipated by a very 
short time. A week or a fortnight might make all the difference between 
a labor of extreme severity and one of comparative ease. 

Condition of the Mother's Health calling for the Operation. — There is 
a large class of cases in which the condition of the mother indicates the 
operation. Many of these have already been considered when treating 
of the diseases of pregnancy. Amongst them may be mentioned vomit- 
ing which has resisted all treatment, and which has produced a state of 
exhaustion threatening to prove fatal ; chorea, albuminuria, convulsions, 
or mania ; excessive anasarca, ascites, or dyspnoea connected with disease 
of the heart, lungs, or liver, which may be, in a great measure, caused 
by the pressure of the enlarged uterus ; in fact, any condition or disease 
affecting the mother, provided only we are convinced that the termina- 
tion of pregnancy would give the patient relief and that its continuance 
would involve serious danger. It need hardly be pointed out that the 
induction of labor for any such causes involves grave responsibility and 
is decidedly open to abuse : no practitioner would, therefore, be justified 
in resorting to it, especially if the child have not reached a viable age, 
without the most anxious consideration. No general rules can be laid 
down. Each case must be treated on its own merits. It is obvious that 
the nearer the patient is to the full period, the greater will be the chance 
of the child surviving, and the less hesitation need then* be felt in con- 
sulting the interest of the mother. 

Conditions Affecting the Safety of the Child alone. — In another class 
of cases the operation is indicated by circumstances affecting the life of 
the child alone. Of these the most common are those in which the child 
dies, in several successive pregnancies, before the termination of utero- 
gestation. This is generally the result of fatty, calcareous, or syphilitic 
degeneration of the placenta, which is thus rendered incapable of per- 
forming its functions. These changes in the placenta seldom commence 
until a comparatively advanced period of pregnancy, so that if labor be 
somewhat hastened Ave may hope to enable the patient to give birth to a 
living and healthy child. The experience of the mother will indicate 
the period at which the death of the foetus has formerly taken place, as 
she would then have appreciated a difference in her sensations, a dim- 



INDUCTION OF PREMATURE LABOR. 451 

inution in the vigor of the foetal movements, a sense of weight and cold- 
ness, and similar signs. For some weeks before the time at which this 
change has been experienced we should carefully auscultate the foetal 
heart from day to day, and in most cases the approach of danger will 
be indicated sufficiently soon, by tumultuous and irregular pulsations 
or a failure in their strength and frequency, to enable us to interfere with 
success. On the detection of these, or on the mother feeling that the 
movements of the child are becoming less strong, the operation should 
at once be performed. Simpson also induced premature labor with suc- 
cess in a patient who had twice given birth to hydrocephalic children. 
In the third pregnancy, which he terminated before the natural period, 
the child was well-formed and healthy. 

Induction of Labor when the Mother is Mortally III. — Some obstetri- 
cians have proposed to induce labor, with the view of saving the child, 
when the mother was suffering from mortal disease. This indication is, 
however, so extremely doubtful, from a moral point of view, that it can 
hardly be considered as ever justifiable. 

Various Methods of Inducing Labor: their Mode of Action. — Th.j 
means adopted for the induction of labor are very numerous. Souu 
of them act through the maternal circulation, as the administration of 
ergot and other oxytocics ; others, by their power of exciting reflex 
action, or by interfering with the integrity of the ovum, or by a com- 
bination of both, as the vaginal douche, separation of the membrane.! 
from the uterine walls, puncture of the ovum, dilatation of the os, stim- 
ulating enemata, or irritation of the breasts. The former class are never 
employed in modern obstetric practice. Of the latter, some offer spe- 
cial advantages in particular cases, but none are equally adapted for 
all emergencies. Often a combination of more methods than one 
will be found most useful. I shall mention the various methods in 
use, and discuss briefly the relative advantages and disadvantages of 
each. 

Puncture of Membranes. — The evacuation of the liquor amnii by the 
puncture of the membranes was the first method practised, and was that 
recommended by Denman and all the earlier writers. It is the most 
certain which can be employed, as it never fails, sooner or later, to induce 
uterine contractions. There are, however, several disadvantages con- 
nected with it which are sufficient to contraindicate its use in the major- 
ity of cases. It is uncertain as regards the time taken in producing the 
desired effect, pains sometimes coming on within a lew hours, but occa- 
sionally not until several days have elapsed. The contracting walls of 
the uterus press directly on the body of the child, which, being frail 
and immature, is less able to bear the pressure than at the full period 
of pregnancy. Hence it involves great risk to the foetus. Besides, the 
escape of the water does away with the fluid wedge SO useful in dilating 
the os, and should version be necessary from malpresentation — a com- 
plication more likely to occur than in natural labor — the operation would 
have to be performed under very unfavorable conditions. These objec- 
tions are sufficient to justify the ordinary opinion that this procedure should 
not be adopted unless other means have been tried and tided. 
now and then cases are met with in which it i- extremely difficult to 



452 OBSTETRIC OPERATIONS. 

arouse the uterus to action, and under such circumstances, in spite of its 
drawbacks, this method will be found to be very valuable. When the 
operation has to be performed before the child is viable — that is, before 
the seventh month — these objections do not hold, and then it is the sim- 
plest and readiest procedure we can adopt. Indeed, in producing early 
abortion no other is practicable. The operation itself is most simple, 
requiring only a quill, stiletted catheter, or other suitable instrument to 
be passed up to the os, carefully guarded by the fingers of the left hand 
previously introduced, and to be pressed against the membranes until 
perforation is accomplished. Meissner of Leipsic has proposed as a 
modification of this plan that the membranes should be punctured 
obliquely three or four inches above the os, so as to admit of a gradual 
and partial escape of the amniotic fluid, thus lessening the risk to the 
child from pressure by the uterus. For this purpose he employed a 
curved silver canula containing a small trocar, which can be projected 
after introduction. The risk of injuring the uterus by such an instru- 
ment would be considerable, and we have other and better means at our 
command which render it unnecessary. When we require to produce 
early abortion, it would be well not to attempt to puncture the mem- 
branes with a sharp-pointed instrument. The object can be effected 
with certainty and greater safety by passing an ordinary uterine sound 
through the os and turning it round once or twice. 

Administration of Oxytocics. — The administration of ergot of rye, 
either alone or combined with borax and cinnamon, has been sometimes 
resorted to. This practice has been principally advocated by Rams- 
botham, who was in the habit of exhibiting scruple doses of the pow- 
dered ergot every fourth hour until delivery took place. Sometimes he 
found that as many as thirty or forty doses were required to effect the 
object ; occasionally, labor commenced after a single dose. Finding 
that the infantile mortality was very great when this method was fol- 
lowed, he modified it, and administered two or three doses only, and if 
these proved insufficient he punctured the membranes. There can be no 
doubt that ergot possesses the power of inducing uterine contractions. 
The risk to the child is, however, quite as great as when the membranes 
are punctured, for not only is it subject to injurious pressure from the 
tumultuous and irregular contractions which the ergot produces, but the 
drug itself, when given in large doses, seems to exert a poisonous influ- 
ence on the foetus. For these reasons ergot may properly be excluded 
from the available means of inducing labor. 

Methods Acting Indirectly on the Uterus. — Various methods have 
been recommended which act indirectly on the uterus, the source of irri- 
tation being at a distance. Thus, D'Outrepont used frequently-repeated 
abdominal frictions and tight bandages. Scanzoni, remembering the 
intimate connection between the mammae and uterus, and the tendency 
which irritation of the former has to induce contraction of the latter, 
recommended the frequent application of cupping-glasses to the breasts. 
Radford and others have employed galvanism. Stimulating enemata 
have been employed. All these methods have occasionally proved suc- 
cessful, and, unlike the former plans we have mentioned, they are not 
attended by any special risk to the child. They are, however, much 



INDUCTION OF PREMATURE LABOR. 



453 



Fig. 149. 




Barnes's Bag for 

Dilating the 

Cervix. 



too uncertain to be relied on, besides being irksome both to the patient 
and practitioner. 

Artificial Dilatation of the Os Uteri. — The artificial dilatation of the 
os uteri, in imitation of its natural opening in labor, was first practised 
by Kliige. He was in the habit of passing within the 
os a tent made of compressed sponge and allowing it to 
dilate by imbibition of fluid. If labor were not pro- 
voked within twenty-four hours, he removed it, and 
introduced one of larger dimensions, changing it as often 
as was necessary until his object was accomplished. Al- 
though this operation seldom failed to induce labor, it 
had the disadvantage of occupying an indefinite time and 
the irritation produced was often painful and annoying. 
Dr. Keiller of Edinburgh was the first to suggest the 
use of caoutchouc bags distended by air as a means of 
dilating the os. This plan has been perfected by Dr. 
Barnes in his well-known dilators, which are of great 
use in many cases in which artificial dilatation of the 
cervix is necessary. They consist of a series of india- 
rubber bags of various sizes, with a tube attached (Fig. 
149), through which water can be injected by an ordi- 
nary Higginson's syringe. They have a small pouch 
fixed externally, in which a sound can be placed, so as to facilitate their 
introduction. When distended with water the bags assume somewhat 
of a fiddle shape, bulging at both extremities, which ensures their being 
retained within the os. When first introduced into practice as a means 
of inducing labor, it was thought that this method gave a complete con- 
trol over the process, so that it could be concluded within a definite time 
at the will of the operator. The experience of those who have used it 
much has certainly not justified this anticipation. It is true that occa- 
sionally contractions supervene within a few hours after dilatation litis 
been commenced, but, on the other hand, the uterus often responds very 
imperfectly to this kind of stimulus, and the bags may be inserted foi 
many consecutive hours without the desired result supervening, the 
puncture of the membranes being eventually necessary in order to hasten 
the process. Indeed, my own experience would lead me to the conclu- 
sion that as a means of evoking uterine contraction cervical dilatation is 
very unsatisfactory. Dr. Barnes himself has evidently -ecu reason to 
modify his original views, for while he at first talked of the bag- as 
enabling us to induce labor with certainty at a given time, he ha- since 
recommended that uterine action should be first provoked by other 
means, the dilators being subsequently used to accelerate the labor thin 
brought on. The bag-, thus employed, find, as I believe, their most 
useful and a very valuable application ; but when used in this way they 
cannot be considered a means of originating uterine action. A subsid- 
iary objection to the bag- is the risk of displacing tin- presenting part 
1 have, for example, introduced them when the head was presenting^ 
ami on their removal found the shoulder lying over the OS. It i- no1 
difficult to understand how the continuous pressure of a distended bag 
in the internal os might easily push away the head, which i bo readily 



454 OBSTETRIC OPERATIONS. 

movable so long as the membranes are unruptured. Still, if labor be in 
progress and the os insufficiently dilated, the possibility of this occur- 
rence is not a sufficient reason for not availing ourselves of the undoubt- 
edly valuable assistance which the dilators are capable of giving. 

Separation of the Membranes. — Some processes for inducing labor act 
directly on the ovum by separating the membranes, to a greater or less 
extent, from the uterine walls. The first procedure of the kind was 
recommended by Dr. Hamilton of Edinburgh, and consisted in the 
gradual separation of the membranes for one or two inches all around 
the lower segment of the uterus. To reach them the finger had to be 
gently insinuated into the interior of the os, which was gradually dilated 
to a sufficient extent by a series of successive operations repeated at 
intervals of three or four hours. When this had been accomplished, the 
fore finger was inserted and swept round between the membranes and the 
uterus ; but it was frequently found necessary to introduce the greater 
part of the hand to effect the object, and sometimes even this -was not 
sufficient, and a female catheter or other instrument had to be used for 
the purpose. The method was generally successful in bringing on labor, 
but it now and then failed, even in Dr. Hamilton's hands. It is cer- 
tainly based on correct principles, but it is tedious and painful both to 
the practitioner and the patient, and very uncertain in its time of action. 
For these reasons it has never been much practised. 

Vaginal and Uterine Douches. — In the year 1836, Kiwisch suggested 
a plan which from its simplicity has met with much approval. It con- 
sists in projecting at intervals a stream of warm or cold water against 
the os uteri. Its action is doubtless complex. Kiwisch himself believed 
that relaxation of the soft parts through the imbibition of water was the 
determining cause of labor. Simpson found that the method failed unless 
the water mechanically separated the membranes from the uterine walls. 
Besides this effect, it probably directly induces reflex action by distend- 
ing the vagina and dilating the os. In using it, it has been customary 
to administer a douche twice daily, and more frequently if rapid effects 
be desired. The number required varies in different cases. The largest 
number Kiwisch found it necessary to use was 17, the smallest 5. The 
average time that elapses before labor sets in is four days. Hence the 
method is obviously useless when rapid delivery is required. 

Dr. Cohen of Hamburg introduced an important modification of the 
process which has been considerably practised. It consists in passing a 
silver or gum-elastic catheter some inches within the os, between the 
membranes and the uterine Avails, and injecting the fluid through it 
directly into the cavity of the uterus. He used creasote or tar-water, 
and injected without stopping until the patient complained of a feeling 
of distension. Others have found the plan equally efficacious when they 
only employed a small quantity of plain water, such as 7 or 8 ounces. 
Professor Lazarewitch of Charkoff is a strong advocate of this method. 
He believes that uterine action is evoked much more rapidly and cer- 
tainly if the water be injected near the fundus, and he has contrived an 
instrument for the purpose with a long metallic nozzle. 

Dangers of these Plans. — So many fatal cases have followed these 
methods that it cannot be doubted that, in spite of their certainty and 



INDUCTION OF PREMATURE LABOR. 455 

simplicity, there is an element of risk in them that should not be over- 
looked. Many of these are recorded in Barnes's work, and he comes to 
the conclusion, which the facts unquestionably justify, that " the douche, 
whether vaginal or intra-uterine, ought to be absolutely condemned as 
a means of inducing labor." The precise reason of the danger is not 
very obvious. Sudden stretching of the uterine walls, producing shock, 
has been supposed to have caused it ; but in many of the fatal cases the 
symptoms have been rather those attending the passage of air into the 
veins, and it is easy to understand how air may have been introduced in 
this way into the large uterine sinuses. 

Injection of Carbonic Acid Gas. — Simpson and Scanzoni have both 
tried with success the injection of carbonic acid gas into the vagina. 
Fatal results have, however, followed its employment, and Simpson has 
expressed an opinion that the experiment should not be repeated. 

Simpson's Method of Operating. — Simpson originally induced labor 
by passing the uterine sound within the os and up toward the fundus, 
and when it has been inserted to a sufficient extent moving it slightly 
from side to side. He was led to adopt this procedure in the belief that 
we might thus closely imitate the separation of the decidua which occurs 
previous to labor at term. Uterine contractions were induced with cer- 
tainty and ease, but it was found impossible to foretell what time might 
elapse between the commencement of labor and the operation, which had 
frequently to be performed more than once. He subsequently modified 
this procedure by introducing a flexible male catheter without a stilette, 
which he allowed to remain in the uterus until contractions were excited. 
This plan is much used in Germany, and is now that which is also most 
frequently adopted in this country. It is simple and very efficacious. 
pains coming on almost invariably within twenty-four hours after the 
catheter or bougie is introduced. A theoretical objection is the possibil- 
ity of the catheter separating a portion of the placenta and giving rise 
to hemorrhage; but in practice this has not been found to occur, and 
the risk might generally be avoided by introducing the catheter at a dis- 
tance from the placenta, the probable situation of which has been ascer- 
tained by auscultation. The more deeply the catheter is introduced, the 
more certain and rapid is its effect, and not less than seven inches should 
be pushed up within the os. It is not always easy to insert it so for, 
especially if a flexible catheter be used, which is apt to be too pliable to 
pas- upward with ease. A solid bougie — male urethral bougie — should 
therefore be employed ; and I have found its introduction greatly facil- 
itated by anaesthetizing the patient and passing the greater part of the 
hand into the vagina. In this way it can be pushed in very gently and 
without any risk of injury to the uterus. There is some chance of rup- 
turing the membranes while pushing it upward. This accident, indeed, 
cannot^ always he avoided, even when the greatesl care is taken ; but 
when it occurs the puncture will be at a distance from Hi" OS, SO thai B 
small portion only of the liquor amnii will escape; and this can scarcely 
be considered a serious objection. It i- always an advantage t<> allow 
the pains to come on gradually and in imitation of natural labor. 
Therefore, if, after the bougie has been inserted for a sufficient time, 
uterine contractions come on sufficiently strongly, we may leave the case 



456 OBSTETRIC OPERATIONS. 

to be terminated naturally ; or if they be comparatively feeble, we may 
resort to aceelerative procedures — viz. dilatation of the cervix by the 
fluid bags, and subsequently the puncture of the membranes. In this 
way we have the labor completely under control ; and I believe this 
method will commend itself to those who have experience of it as the 
simplest and most certain mode of inducing labor yet known, and the 
one most closely imitating the natural process. Of late I have been in 
the. habit of combining dilatation of the cervix with this method by 
means of a well-carbolized sponge tent passed into the cervix after the 
bougie is in position. In ten or twelve hours, when the tent and bougie 
are removed, the cervix is found well dilated and ready for the passage 
of the child. 

The Child is Immature and Dijficidt to Rear.— It should not be for- 
gotten that the child is immature, and that unusual care is likely to be 
required to rear it successfully. We should, therefore, be careful to 
have at hand all the usual means of resuscitation ; and, as the mother 
may not be able to nurse at once, it would be a good precaution to have 
a healthy wet-nurse in readiness. [*] 

[Through the kindness of Dr. Cesare Belluzzi of Bologna I have 
received his two reports, containing the records of 112 cases in which 
he brought on labor prematurely, with a saving of 104 mothers and the 
delivery of as many living children. 42 patients were treated in private 
practice and 70 in the Maternity of Bologna. In 9 patients labor was 
induced because of disease in the mother ; in 1 it was brought on be- 
cause the foetus had usually died in the ninth month of former preg- 
nancies; and in 102 the pelvis was contracted. Of these 102, 6 died — 3 
out of 38 in private practice, and 3 out of 64 in the hospital. Of the 
9 women operated upon because of serious disease, 7 recovered. 35 out 
of 42 infants were delivered alive in private practice, and 62 out of 70 
in the Maternity. 

Dr. Ludwig Winckel of Mulheim, Germany, has also sent me his 
record of 25 deliveries in women who were all the subjects of contrac- 
tion of the pelvis. These patients all recovered: 14 children were still- 
born and 13 were living ; of the latter, only 7 were alive at the end of 
two weeks. The prolonged vitality of the foetus is largely dependent 
upon the period in gestation which is chosen for the operation : the 
later the delivery, the better is the prospect of ultimate safety. But 
a small proportion of the children reach maturity. Of 32 delivered 
alive in hospital in a period of less than ten years under Dr. Belluzzi, 
27 were dead before the expiration of the first year, and 29 in all 
within two years of birth. — Ed.] 

[ T In some of the European maternities they now have in use a little heated cham- 
ber in which the infant is put to sleep ; it is kept warm, on the principle of an egg- 
hatching machine, by a lamp and water-chamber. — Ed.] 



TURNING. 457 



CHAPTER II. 
TUKXIXG. 

History of the Operation. — Turning — by which we mean the alteration 
of the position of the foetus, and the substitution of some other portion 
of the body for that originally presenting — is one of the most important 
of obstetric operations and merits careful study. It is also one of the 
most ancient, and was evidently known to the Greek and Roman phy- 
sicians. Up to the fifteenth century, cephalic version — that in which 
the head of the foetus is brought over the os uteri — was almost exclus- 
ively practised, when Pare and his pupil Guillemeau taught the pro- 
priety of bringing the feet down first. It was by the latter physician 
especially that the steps of the operation were clearly defined ; and the 
French have undoubtedly the merit both of perfecting its performance 
and of establishing the indications which should lead to its use. Indeed, 
it was then much more frequently performed than in later times, since 
no other means of effecting artificial delivery were known which did not 
involve the death of the child ; and practitioners doubtless acquired 
great skill in its performance, and were inclined to overrate its import- 
ance and extend its use to unsuitable cases. An opposite error was 
fallen into after the invention of the forceps, which for a time led to 
the abandonment of turning in certain conditions for which it was well 
adapted and in which it has only of late years been again practised. 

Cephalic Version. — Cephalic version has, since Pare wrote, been 
recommended and practised from time to time, but the difficulty of 
performing it satisfactorily was so great that it never became an estab- 
lished operation. Dr. Braxton Hicks has perfected a method by which 
it can be accomplished with greater ease and certainty, and which ren- 
ders it a legitimate and satisfactory resort in suitable cases. To him we 
are also indebted for introducing a method of turning without passing 
the entire hand into the cavity of the uterus, which, under favorable 
circumstances, is not only easy of performance, but deprives the opera- 
tion of one of its greatest dangers. 

Turning by External and Internal Manipulation. — The possibility of 
effecting version by external manipulation has long been known, and 
was distinctly referred to and recommended by Dr. John Pechey 1 so far 
back as the year 1698. Since that time it has been strongly recom- 
mended by Wigand and his followers; and various authors in this 
country, notably Sir James Simpson, have referred to the advantage to 
be derived from external manipulation assisting the hand in the interior 
of the uterus.. In 1854, Dr. Wright of Cincinnati advocated the appli- 
cation of the bi-manual method in arm and shoulder presentations, 
chiefly with the view of effecting cephalic version. To Dr. Hicks, 
however, incontestably belongs the merit of having been the first dis- 

1 The Complete Midwife's Practice, p. 142. 



458 OBSTETRIC OPERATIONS. 

tinctly to show the possibility of effecting complete version in all cases 
in which the operation is indicated by combined external and internal 
manipulation, of laying down definite rules for its practice, and for thus 
popularizing one of the greatest improvements in modern midwifery. 

Object and Nature, of the Operation. — The operation is entirely de- 
pendent for success on the fact that the child in utero is freely mova- 
ble, and that its position may be artificially altered with facility. As 
long as the membranes are unruptured and the foetus is floating in the 
surrounding fluid medium, it is liable to constant changes in position, as 
may be readily demonstrated in the latter months of pregnancy ; and 
the operation under these circumstances may be performed with the 
greatest facility. Shortly after the liquor amnii has escaped there is 
still, as a rule, no great difficulty in effecting version, but, as the body 
is no longer floating in the surrounding liquid, its rotation must neces- 
sarily be attended with some increased risk of injury to the uterus. If 
the liquor amnii have been long evacuated and the muscular structure 
of the uterus be strongly contracted, the foetus may be so firmly fixed 
that any attempt to move it is surrounded with the greatest difficul- 
ties, and may even fail entirely or be attended with such risks to the 
maternal structures as to be quite unjustifiable. 

Cases Suitable for the Operation. — Version may be required either 
on account of the mother or child alone, or it may be indicated by some 
condition imperilling both and rendering immediate delivery necessary. 
The chief cases in which it is resorted to are those of transverse presen- 
tation, where it is absolutely essential ; accidental or unavoidable hem- 
orrhage ; certain cases of contracted pelvis ; and some complications, 
especially prolapse of the funis. The special indications for the opera- 
tion have been separately discussed under these subjects. 

Statistics and Dangers of the Operation. — The ordinary statistical 
tables cannot be depended on as giving any reliable results as to the 
risks of the operation. Taking all cases together, Dr. Churchill esti- 
mates the maternal mortality as 1 in 16, and the infantile as 1 in 3. 
Like all similar statistics, they are open to the objection of not distin- 
guishing between the results of the operation itself and of the cause 
which necessitated interference. Still, they are sufficient to show that 
the operation is not free from grave hazards, and that it must not be 
undertaken without clue reflection. The principal dangers will be dis- 
cussed as we proceed. It may suffice to mention here that those to the 
mother must vary with the period at which the operation is undertaken. 
If version be performed early, before the rupture of the membranes, or 
in favorable cases without the introduction of the hand into the interior 
of the uterus, the risk must of course be infinitely less than in those 
more formidable cases in which the waters have long escaped and the 
hand and arm have to be passed into an irritable and contracted uterus. 
But even in the most unfavorable cases accidents may be avoided if the 
operator bear constantly in mind that the principal danger consists in 
laceration of the uterus or vagina from undue force being employed or 
from the hand and arm not being introduced in the axis of the passages. 
There is no operation in which gentleness, absence of all hurry, and 
complete presence of mind are so essential. A certain number of cases 



TURNING. 459 

end fatally from shock or exhaustion or from subsequent complications. 
As regards the child, the mortality is little, if at all, greater than in 
original breech and footling presentations. iSTor is there any good rea- 
son why it should be so, seeing that cases of turning, after the feet are 
brought through the os, are virtually reduced to those of feet presenta- 
tion, and that the mere version, if effected sufficiently soon, is not likely 
to add materially to the risk to which the child is exposed. 

Version by External Manipulation. — The possibility of effecting ver- 
sion by external manipulation has been recognized by various authors, 
and was made the subject of an excellent thesis by Wigand, who clearly 
described the manner of performing the operation. In spite of the man- 
ifest advantages of the procedure, and the extreme facility with which it 
can be accomplished in suitable cases, it has by no means become the 
established custom to trust to it, and probably most practitioners have 
never attempted it, even under the most favorable conditions. The pos- 
sibility of the operation is based on the extreme mobility of the fetus 
before the membranes are ruptured. After the waters have escaped the 
uterine walls embrace the foetus more or less closely, and version can no 
longer be readily performed in this manner. 

Cases Suitable for the Operation. — It may, therefore, be laid down as 
a rule that it should only be attempted when the abnormal position of 
the foetus is detected before labor lias commenced, or in the early stage 
of labor when the membranes are unruptured. It is also unsuitable for 
any but transverse presentations, for it is not meant to effect complete 
evolution of the foetus, but only to substitute the head for the upper 
extremity. It is useless whenever rapid delivery is indicated, for after 
the head is brought over the brim the conclusion of the case must be left 
to the natural powers. 

The manner of detecting the presentation by palpation lias been already 
described (p. 121), and the success of the operation depends on our being 
able to ascertain the positions of the head and breech through the ute- 
rine walls. Should labor have commenced and the os be dilated, the 
transverse presentation may be also made out by vaginal examination. 
Should the abnormal presentation be detected before labor has actually 
begun, it is in most cases easy enough to alter it and to bring the foetus 
into the longitudinal axis of the uterine cavity. Pinard 1 recommends 
that alter this has been done the foetus should be maintained in position 
by a well-fitting elastic abdominal belt. It is seldom, however, discov- 
ered until labor has commenced, and, even if it be altered, the child is 
extremely apt to resume in a short time the faulty position in which it 
was formerly lying. Still, there can be no harm in making the attempt, 
since the operation itself is in no way painful, and is absolutely without 
risk either to the mother or child. When the transverse presentation is 
detected early in labor, I believe it is good practice to endeavor t<> rem- 
edy it by external manipulation, and if it fail we may at once proceed 
to other and more certain method- of operating. The procedure it-ell' 
is abundantly simple. The patient is placed on her back, and the posi- 
tion of the foetus ascertained by palpation as accurately as possible, in 
the manner already described. The palms of the hands being then 

1 De la Version par Manoeuvre* externa. Pari-, 1878 



460 OBSTETRIC OPERATIONS. 

placed over the opposite poles of the foetus, by a series of gentle gliding 
movements the head is pushed toward the pelvic brim, while the breech 
is moved in the opposite direction. The facility with which the foetus 
may sometimes be moved in this way can hardly be appreciated by 
those who have .never attempted the operation. As soon as the change 
is effected the long diameters of the foetus and the uterus will corre- 
spond, and vaginal examination will show that the shoulder is no longer 
presenting and that the head is over the pelvic brim. If the os be suf- 
ficiently dilated and labor in progress, the membranes should now be 
punctured, and the position of the foetus maintained for a short time by 
external pressure until we are certain that the cephalic presentation is 
permanently established. If labor be not in progress, an attempt may 
at least be made to effect the same object by pads and a binder, one pad 
being placed on the side of the uterus in the situation of the breech, and 
another on the opposite side in the situation of the head. 

Cephalic Version. — On account of the difficulty of performing cephalic 
version in the manner usually recommended, it has practically scarcely 
been attempted, and with the exception of some more recent authors it 
is generally condemned by writers on systematic midwifery. Still, the 
operation offers unquestionable advantages in those transverse presenta- 
tions in which rapid delivery is not necessary, and in which the only 
object of interference is the rectification of malposition ; for if successful 
the child is spared the risk of being drawn footling through the pelvis. 
The objections to cephalic version are based entirely on the difficulty of 
performance ; and, undoubtedly, to introduce the hand within the ute- 
rus, search for, seize, and afterward place the slippery head in the brim 
of the pelvis, could not be an easy process even under the most favor- 
able circumstances, and must always be attended with considerable risk 
to the mother. Velpeau, who strongly advocated the operation, was of 
opinion that it might be more easily accomplished by pushing up the 
presenting part than by seizing and bringing down the head. Wigand 
more distinctly pointed out that the head could be brought to a proper 
position by external manipulation, aided by the fingers of one hand 
within the vagina. Braxton Hicks has laid clown clear rules for its 
performance which render cephalic version easy to accomplish under 
favorable conditions, and will doubtless cause it to become a recognized 
mode of treating malpositions. The number of cases, however, in which 
it can be performed, must always be limited, since, as in turning by ex- 
ternal manipulation alone, it is necessary that the liquor amnii should 
be still retained, or at least have only recently escaped ; that the pres- 
entation be freely movable about the pelvic brim ; and that there be no 
necessity for rapid delivery. Dr. Hicks does not believe protrusion of 
the arm to be a contraindication, and advises that it should be carefully 
replaced within the uterus. When, however, protrusion of the arm has 
occurred, the thorax is so constantly pushed down into the pelvis that 
replacement can neither be safe nor practicable, except under unusually 
favorable conditions, and podalic version will be necessary. 

Jfcthod of Performance. — It is impossible to describe the method of 
performing cephalic version more concisely and clearly than in Dr. 
Hicks' own words. " Introduce," he says, " the left hand into the vagina, 



TUEXIXG. 461 

as in podalic version ; place the right hand on the outside of the abdo- 
men, in order to make out the position of the foetus and the direction 
of its head and feet. Should the shoulder, for instance, present, then 
push it with one or two fingers in the direction of the feet. At the same 
time pressure with the other hand should be exerted on the cephalic end 
of the child. This will bring the head down to the os ; then let the 
head be received on the tips of the inside fingers. The head will play 
like a ball between the two hands ; it will be under their command, and 
can be placed in almost any part at will. Let the head then be placed 
over the os, taking care to rectify any tendency to face presentation. It 
is as well, if the breech will not rise to the fundus readily after the head 
is fairly in the os, to withdraw the hand from the vagina, and with it 
press up the breech from the exterior. The hand which is retaining 
gently the head from the outside should continue there for some little 
time till the pains have ensured the retention of the child in its new 
position and the adaptation of the uterine walls to its new form. Should 
the membranes be perfect, it is advisable to rupture them as soon as the 
head is at the os uteri ; during their flow and after, the head will move 
easily into its proper position." 

The procedure thus described is so simple, and would occupy so short 
a time, that there can be no objection to trying it. Should we fail in 
our endeavors, we shall not be in a worse position for effecting delivery 
by podalic version, which can be proceeded with without withdrawing 
the hand from the vagina or in any way altering the position of the 
patient. 

Podalic Version. — The method of performing podalic version varies 
with the nature of each particular case. In describing the operation it 
has been usual to divide the cases into those in which the circumstances 
are favorable and the necessary manoeuvres easily accomplished, and 
those in which there are likely to be considerable difficulties and in- 
creased risk to the mother. This division is eminently practicable, since 
nothing can be more variable than the circumstances under which ver- 
sion may be required. Before describing the steps of the operation it 
may be well to consider some general conditions applicable to all cases 
alike. 

Position of the Patient. — In this country the ordinary position on the 
left side is usually employed. On the Continent and in America tin 1 
patient is placed on her back, with the legs supported by assistants, as 
in lithotomy. The former position is preferable, not only as a matter 
of custom and as involving much less fuss and exposure of the person, 
but because it admits of both the operator's hands being more easily 
used in concert. In certain difficult cases, when the liquor antiiii has 
escaped and the back of the child is turned toward the spine of the 
mother, the dorsal decubitus presents some advantages in enabling the 
hand to pass more readily over the body of the child ; but such cases 
are comparatively rare. The patient should be brought to the side of 
the bed, across which she should be laid with the hips projecting over 
and parallel to the edge, the knees being flexed toward the abdomen and 
separated from each other by a pillow or by an assistant Assistants 
should also be placed so as to restrain the patient if accessary, and pre- 



462 OBSTETRIC OPERATIONS. 

vent her involuntarily starting from the operator, as this might not only 
embarrass his movements, but be the cause of serious injury. 

Administration of Anaesthetics. — The exhibition of anaesthetics is 
peculiarly advantageous. There is nothing which tends to facilitate the 
steps of the process so much as stillness on the part of the patient and 
the absence of strong uterine contraction. When the vagina is very 
irritable and the uterus firmly contracted round the body of the child, 
complete anaesthesia may enable us to effect version, when without it we 
should certainly fail. 

Period when the Operation should be Undertaken. — The most favorable 
time for operating is when the os is fully dilated, before or immediately 
after the rupture of the membranes and the discharge of the liquor 
amnii. The advantage gained by operating before the waters have es- 
caped cannot be overstated, since we can then make the child rotate with 
great facility in the fluid medium in which it floats. In the ordinary 
operation, in which the hand is passed into the uterus, it is essential to 
wait until the os is of sufficient size to admit of its being introduced 
with safety. This may generally be done when the os is the size of a 
crown-piece, especially if it be soft and yielding. 

Choice of Hand to be Used. — The practice followed with regard to the 
hand to be used in turning varies considerably. Some accoucheurs 
always employ the right hand, others the left, and some one or other 
according to the position of the child. In favor of the right hand it is 
said that most practitioners have more power with it and are able to use 
it with greater gentleness and delicacy. In transverse presentations, if 
the abdomen of the child be placed anteriorly, the right hand is said to 
be the proper one to use, on account of the greater facility with which 
it can be passed over the front of the child ; and in difficult cases of this 
kind, when we are operating with the patient on her back, it certainly 
can be employed Avith more precision than the left. In all ordinary 
cases, however, the left hand can be introduced much more easily in the 
axis of the passages ; the back of the hand adapts itself readily to the 
curve of the sacrum, and, even when the child's abdomen lies anteriorly, 
it can be passed forward without difficulty so as to seize the feet. These 
advantages are sufficient to recommend its use, and very little practice is 
required to enable the practitioner to manipulate with it as freely as with 
the right. If, in addition, we remember that the right hand is required 
to operate on the foetus through the abdominal walls — and this is a point 
which should never be forgotten — we shall have abundant reasons for 
laying it down as a rule that the left hand should generally be employed. 
Before passing the hand and arm they should be freely lubricated, with 
the exception of the palm, which is left untouched to admit of a firm 
grasp being taken of the foetal limbs. It is also advisable to rem'ove 
the coat and bare the arm as high as the elbow. 

As it should be a cardinal rule to resort to the simplest procedure 
when practicable, it will be well to consider first the method by com- 
bined external and internal manipulation, without passing the hand into 
the uterus, and subsequently that which involves the introduction of the 
hand. 

Turning by Combined External and Internal Manipulation. — To effect 



TUBXIXG. 



463 



podalic version by the combined method it is an essential preliminary to 
ascertain the situation of the foetus as accurately as possible. It will 
generally be easy in transverse presentation to make out the breech and 
head by palpation, while in head presentations the fontanelles will show 
to which side of the pelvis the face is turned. The left hand is then to 
be passed carefully into the vagina, in the axis of the canal, to a suf- 
ficient extent to admit of the fingers passing freely into the cervix. To 
effect this it is not always necessary to insert the whole hand, three or 
four fingers being generally sufficient. 

If the head lie in the first or fourth position, push it upward and to the 
left, while the other hand, placed externally on the abdomen, depresses 

Fig. 150. 




ojm v 




First Stage of Bi-polar Version: Elevation of the Head and Depression 
of the Breech. (After BariR-.-.i 

the breech toward the right (Fig. 150). By this means we aci simulta- 
neously on both extremities <»t* the child'- body and easily alter it- 
position. The breech i- pushed down gently but firmly by gliding the 
band over the abdominal wall. The head will now pa— out of reach, 
and the shoulders will arrive at the <»- and will lie on the tips of the 
fingers. This is similarly pushed upward in the same direction a- the 
head ( Fig. 1 51 ), the breech at the same time being -till further depress d 
until the knee comes within reach <>(' the fingers, when (the membranes 
being now ruptured, if still unbroken) it i- seized and pulled down 
through the os (Fig. 152). Occasionally the (bo( comes immediately 
over the os when it can he seized instead of the knee. Version may be 
facilitated by changing the position <>t' the external hand and pushing 



464 OBSTETRIC OPERATIONS. 

the head upward from the iliac fossa, instead of continuing the attempt 
to depress the breech (Figs. 152 and 153). These manipulations should 
always be carried on in the intervals, and desisted from when the pains 

Fig. 151. 




Second Stage of Bi-polar Version : Elevation of the Shoulders and 
Depression of the Breech. (After Barnes.) 

come on ; and when the pains recur with great force and frequency the 
advantage of chloroform Avill be particularly apparent. In the second 

Fig. 152. 




Third Stage of Bi-polar Version : Seizure of the Knee and Partial 
Elevation of the Head. (After Barnes.) 

and third positions the steps of the operation should be reversed : the 
head is pushed upward and to the right, the breech downward and to 
the left. When the position cannot be made out with certainty, it is well 



TUBXIXG. 



465 



to assume that it is the first, since that is the one most frequently met 
with ; and even if it be not, no great inconvenience is likely to occur. 
If the os be not sufficiently open to admit of delivery being concluded, 
the lower extremity can be retained in its new position with one finger 
until dilatation is sufficiently advanced or until the uterus has perina- 



Fig. 153. 




Fourth Stage of Bi-polar Version : Drawing Down of the Legs 
and Completion of Version. (After Barnes.) 

nently adapted itself to the altered position of the child ; cither of which 
results will generally be effected in a short space of time. 

In transverse presentations the same means are to be adopted, the 
shoulder being pushed upward in the direction of the head, while the 
breech is depressed from without. This is frequently sufficient to bring 
the knees within reach, especially if the membranes are entire, hut ver- 
sion is much facilitated by pressing the head upward from without. 
alternately with depression of the breech, [f the liquor amnii has 
escaped, and the uterus is firmly contracted round the body of the child, 
it will be found impossible to effect an alteration in its position without 
the introduction of the hand, and the ordinary method of turning musl 
beemployed. The peculiar advantage of the combined process is thai 
it in no way interferes with the latter, lor should it not succeed the band 
can he passed on into the uterus without withdrawal from the vagina 
(ptovided the os be sufficiently dilated) and th<- feel or knees seized and 
brought down. 

Podalic Verdcm when the 1I"i«I is Introduced into th* Uterus. — Turn- 
ing with the hand introduced into the uterus, provided the water- have 
not or have only recently escaped and the os !"■ sufficiently dilated, is an 
operation generally performed with ease. 

30 



466 



OBSTETRIC OPERATIONS. 



Introduction of the Hand. — The first step, and one of the most 
important, is the introduction of the hand and arm. The fingers hav- 
ing been pressed together in the form of a cone, the thumb lying 
between the rest of the fingers, the hand, thus reduced to the smallest 
possible dimensions, is slowly and carefully passed into the vagina in 
the axis of the outlet in an interval between the pains, and passed 
onward in the same cautious manner and with a semi-rotatory motion 
until it lies entirely within the vagina, the direction of introduction 
being gradually changed from the axis of the outlet to that of the brim. 
If uterine contractions come on, the hand should remain passive until 
they are over. It should ever be borne in mind as one of the funda- 
mental rules in performing version that we should act only in the 
absence of pains, and then with the utmost gentleness, all force and 
violent pushing being avoided. The hand, still in the form of a cone, 
having arrived at the os, if this be sufficiently dilated may be passed 
through at once. If the os be not quite open, but dilatable, the points 
of the fingers may be gently insinuated and occasionally expanded, so 
as to press it open sufficiently to permit the rest of the hand to pass. 
While this is being done the uterus should be steadied by the other hand 

Fig. 154. 




Seizure of the Feet when the Hand is Introduced into the Uterus. 

placed externally or by an assistant. If the presentation should not 
previously have been made out with accuracy, we can now ascertain 
how to pass the hand onward, so that its palmar surface may correspond 
with the abdomen of the child. 



TURNING. 



467 



Rupture of the Membranes. — The membranes should now be ruptured 
— if possible during the absence of pain — so as to prevent the waters 
being forced out. The hand and arm form a most efficient plug, and 
the liquor amnii cannot escape in any quantity. Some practitioners 
recommend that before rupturing the membranes the hand should be 
passed onward between them and the uterine walls until we reach the 
feet. By so doing we run the risk of separating the placenta ; besides, 
we have to introduce the hand much farther than may be necessary, 
since the knees are often found lying quite close to the os. As soon as 
the membranes are perforated, the hand can be passed on in search of 

Fig. 155. 




Drawing Down of the Feet and Completion of Version. 

the feet (Fig. 154). At this stage of the operation increased eare is 
necessary to avoid anything like force, and should a pain come on the 
hand must be kept perfectly flat and still, and rather pressed on the 
body of the child than on the uterus. I!" the pains be strong, much 
inconvenience may be felt from the compression J and were the onward 
movement continued, or the hand even kepi bent in the conical form in 

which it was introduced, rupture of the uterine walls mighl easily '><' 
caused. This is not likely to occur in the class of cases now under con- 
sideration, for it is chiefly when the water- have Long escaped that the 
progress of the hand is a matter of difficulty. Valuable assistance may 
now be given by pressing the breech downward from without. -<> a- t«> 
bring the knees or feet more easily within the reach of the internal hand. 



468 OBSTETRIC OPERATIONS. 

Having arrived at the knees or feet, they may be seized between the fin- 
gers and drawn downward in the absence of a pain (Fig. 155). This 
will cause the foetus to revolve on its axis, the breech will descend, and 
at the same time the ascent of the head may be assisted by the right 
hand from without. It is a question with many accoucheurs which part 
of the inferior extremities should be seized and brought down. Some 
recommend us to seize both feet, others prefer one only, while some 
advise the seizure of one or both knees. In a simple case of turning, 
before the escape of the waters, it does not matter much which of these 
plans is followed, since version is accomplished with the greatest ease by 
any one of them. The seizure of the knee, however, instead of the feet, 
offers certain advantages which should not be overlooked. It is gen- 
erally more accessible, affords a better hold (the fingers being inserted in 
the flexure of the ham), and, being nearer the spine, traction acts more 
directly on the body of the child. Any danger of mistaking the knee 
for the elbow may be obviated by remembering the simple rule that the 
salient angle of the former when the thigh is flexed looks toward the 
head of the child, of the latter toward its feet. Certain advantages may 
also be gained by bringing down one foot or knee only, instead of both. 
When one inferior extremity remains flexed on the body of the child, 
the part which has to pass through the os is larger than when both legs are 
drawn down, and consequently the os is more perfectly dilated, and less 
difficulty is likely to be experienced in the delivery of the rest of the 
body, so that the risk to the child is materially diminished. 

Choice of the Leg to be brought down in Transverse Presentation. — 
Simpson, whose views have been adopted by Barnes and other writers, 
recommends the seizing, if possible, in arm presentations, of the knee 
farthest from and opposite to the presenting arm, as by this means the 
body is turned round on its longitudinal axis and the presenting arm 
and shoulder more easily withdrawn from the os. Dr. Galabin has 
carefully investigated this point in a recent paper, 1 and contends that 
there is a greater mechanical advantage in seizing the leg which is near- 
est to, and on the same side as, the presenting arm ; and this, moreover, 
is generally more readily done. 

Management of the Case after Version. — As soon as the head has 
reached the fundus and the lower extremity is brought through the os, 
the case is converted into a foot or knee presentation, and it comes to be 
a question whether delivery should now be left to nature or terminated 
by art. This must depend to a certain extent on the case itself and on 
the cause which necessitated version, but generally it will be advisable 
to finish delivery without unnecessary delay. To accomplish this, 
downward traction is made during the pains, and desisted from in the 
intervals (Fig. 156). As the umbilical cord appears, a loop should be 
drawn down ; and if the hands be above the head, they must be disen- 
gaged and brought over the face in the same manner as in an ordinary 
footling presentation. The management of the head after it descends 
into the cavity of the pelvis must also be conducted as in labors of that 
description. 

Turning in Placenta Prwvia. — In cases of placenta previa the os will, 

1 Obst. Trans., vol. xix , 1877. 



TURNING. 



469 



as a rule, be more easily dilatable than in transverse presentations. 
Hicks' method offers the great advantage of enabling us to perform 
version much sooner than was formerly possible, since it only requires 
the introduction of one or two fingers into the os uteri. Should we not 
succeed by it, and the state of the patient indicates that delivery is neces- 
sary, we have at our command in the fluid dilators a means of artificially 
dilating the os uteri which can be employed with ease and safety. If 
we have to do with a case of entire placental presentation, the hand 
should be passed at that point where the placenta seems to be least 
attached. This will always be better than attempting to perforate its 

Fig. 156. 




Showing the Completion of Version. (After Barnes.) 

substance — a measure sometimes recommended, but more easily per- 
formed in theory than in practice. If the placenta only partially 
present, the hand should, of course, be inserted at its free border. It 
will frequently be advisable not to hasten delivery after the feet have 
been brought through the os, for they form of themselves a very efficient 
plug and effectually prevent further loss of blood ; while, if the patient 
be much exhausted, she may have her strength recruited by stimulants, 
etc. before the completion of delivery. 

Turning in Abdomino-amierior Positions. — In abdomino-anterior posi- 
tions in which the waters have escaped, and in which, therefore, some 
difficulty may be reasonably anticipated, the operation is generally more 
easily performed with the patient on her back ; the right hand is then 
introduced into the uterus and the left employed externally (Fig. I ; >7>. 



470 



OBSTETRIC OPERATIONS. 



In this way the internal hand has to be passed a shorter distance and in 
a less constrained position. The operator then sits in front of the 
patient, who is supported at the edge of the bed in the lithotomy position 

Fig. 157. 




Showing the Use of the Right Hand in Abdomino-anterior Position. 

with the thighs separated, and the right hand is passed up behind the 
pubes and over the abdomen of the child. 

Difficult Cases of Arm Presentation. — The difficulties of turning cul- 
minate in those unfavorable cases of arm presentation in which the mem- 
branes have been long ruptured, the shoulder and arm pressed down 
into the pelvis, and the uterus contracted round the body of the child. 
The uterus being firmly and spasmodically contracted, the attempt to 
introduce the hand often only makes matters worse by inducing more 
frequent and stronger pains. Even if the hand and arm be successfully 
passed, much difficulty is often experienced in causing the body of the 
child to rotate ; for we have no longer the fluid medium present in 
which it floated and moved with ease, and the arm of the operator may 
be so cramped and pained by the pressure of the uterine walls as to be 
rendered almost powerless. The risk of laceration is also greatly in- 
creased, and the care necessary to avoid so serious an accident adds much 
to the difficulty of the operation. 

Value of Anaesthesia in Relaxing the Uterus. — In these perplexing 
cases various expedients have been tried to cause relaxation of the spas- 
modically contracted uterine fibres, such as copious venesection in the 
erect attitude until fainting is induced, warm baths, tartar emetic, and 
similar depressing agents. None of these, however, are so useful as the 
free administration of chloroform, which lias practically superseded them 
all, and often answers most effectually when given to its full surgical 
extent. 



TURNING. 471 

Mode of Procedure. — The hand must be introduced with the precau- 
tions already described. If the arm be completely protruded into the 
vagina, we should pass the hand along it as a guide, and its palmar sur- 
face will at once indicate the position of the child's abdomen. Xo ad- 
vantage is gained by amputation, as is sometimes recommended. When 
the os is reached the real difficulties of the operation commence, and, if 
the shoulder be firmly pressed down into the brim of the pelvis, it may 
not be easy to insinuate the hand past it. It is allowable to repress the 
presenting part a little, but with extreme caution, for fear of injuring 
the contracted uterine parietes. It is better to insinuate the hand past 
the obstruction, which can generally be done by patient and cautious 
endeavors. Having succeeded in passing the shoulder, the hand is to 
be pressed forward in the intervals, being kept perfectly flat and still on 
the body of the foetus when the pains come on. It is much safer to 
press on it than on the uterine walls, which might readily be lacerated 
by the projecting knuckles. When the hand has advanced sufficiently 
far, it will be better, for the reasons already mentioned, to seize and 
bring down one knee only. 

Management of Cases in which the Foot is brought down, but the Fains 
will not Revolve. — Even when the foot has been seized and brought 
through the os, it is by no means always easy to make the child revolve 
on its axis, as the shoulder is often so firmly fixed in the pelvic brim as 
not to rise toward the fundus. Some assistance may be derived from 
pushing the head upward from without, which, of course, would raise 
the shoulder along with it. If this should fail, we may effect our object 
by passing a noose of tape or wire ribbon round the limb, by which 
traction is made downward and backward ; at the same time the other 
hand is passed into the vagina to displace the shoulder and push it out 
of the brim. It is evident that this cannot be done as long as the limb 
is held by the left hand, as there is no room for both hands to pass into 
the vagina at the same time. By this manoeuvre version may be often 
completed when the foetus cannot be turned in the ordinary way. 
Various instruments have been invented, both for passing a lac round 
the child's limb and for repressing the shoulder, but none of them 
can compete, either in facility of use or safety, with the hand of the ac- 
coucheur. 

If all Attempts at Version Fail, Mutihiixm of the Foetus is Necessary. — 
Should all attempts at version fail, no resource is left but the mutilation 
of the child, either by evisceration or decapitation. This extreme meas- 
ure is, fortunately, seldom necessary, as with due care version may gen- 
erally l)e effected, even under the most unfavorable circumstances. 



472 OBSTETRIC OPERATIONS. 



CHAPTEE III. 

THE FOKCEPS. 

Of all obstetric operations, the most important, because the most truly 
conservative both to the mother and child, is the application of the for- 
ceps. In modern midwifery the use of the instrument is much extended, 
and it is now applied by some of our most experienced accoucheurs with 
a frequency which older practitioners would have strongly reprobated. 
That the injudicious and unskilful use of the forceps is capable of doing 
much harm no one will for a moment deny. This, however, is not a 
reason for rejecting the recommendation of those who advise a more 
frequent resort to the operation, but rather for urging on the practitioner 
the necessity of carefully studying the manner of performing it, and of 
making himself familiar with the cases in which it is easy or the reverse. 
Nothing but practice — at first on the manikin, and afterward in actual 
cases — can impart the operative dexterity which it should be the aim of 
every obstetrician to acquire, and without which there can be no assur- 
ance of his doing his duty to his patient efficiently. 

Description of the Instrument. — The forceps may best be described as 
a pair of artificial hands by which the foetal head may be grasped and 
drawn through the maternal passages by a vis a fronte when the vis a 
tergo is deficient. This description will impress on the mind the im- 
portant action of the instrument as a tractor, to which all its other 
powers are subservient. The forceps consists of two separate blades 
of a curved form adapted to fit the child's head, a lock by which the 
blades are united after introduction, and handles which are grasped 
by the operator and by means of which traction is made. It would 
be a wearisome and unsatisfactory task to dwell on all the modifications 
of the instrument which have been made, which are so numerous as to 
make it almost appear as if no one could practise midwifery with the 
least pretension to eminence unless he has attached his name to a new 
variety of forceps. 

The Short Forceps. — The original instrument, invented by the Cham- 
berlens, may be looked upon as the type of the short straight forceps, 
which has been more employed than any other, and which perhaps 
finds its best representative in the short forceps of Denman (Fig. 158). 
Indeed, the only essential difference between the two is the lock of the 
latter, originally invented by Smellie, which is so excellent that it has 
been adopted in all British forceps, and which, for facility of juncture, 
is much superior to either the French pivot or the German lock, while 
for firmness it is, for all practical purposes, as good as either. In this 
instrument the blades are 7, the handles 4§ , inches in length ; the extremi- 
ties of the blades are exactly 1 inch apart, and the space between them 
at their widest part is 2-J inches. The blades measure If inches at their 
greatest breadth, and spring with a regular sweep directly from the lock, 



THE FORCEPS. 



Fig. 158. 



there being no shank. The blades are formed of the best and most 
highly-tempered steel to resist the strain to which they are occasion- 
ally subjected, and they are smooth and 
rounded on their inner surface to obviate 
the risk of injury to the scalp of the 
child. 

Advantage Claimed for this Form 
of Instrument. — The special advantage 
claimed for this form of instrument is 
that, the two halves being precisely simi- 
lar, no care or forethought is required on 
the part of the practitioner as to which 
blade should be introduced uppermost — 
an advantage of no great value, since no 
one should undertake a case of forceps 
delivery who has not sufficient know- 
ledge of the operation and presence of 
mind enough to obviate any risk from 
the introduction of the wrong blade 
first. On account of its shortness and 
the want of the second or pelvic curve, 
it is only adapted for cases in which the 
head is low down in the pelvis or actu- 
ally resting on the perineum. 

The Pelvic Curve : its Advantages. — 
The question of the second or pelvic 
curve is one on which there is much 
difference of opinion. The forceps we 
are now considering — and the many modifications formed on the same 
plan — is constructed solely with reference to its grasp on the child's 
head, and without regard to the axes of the maternal 
passages. Consequently, were we to introduce it wJien 
the head was at the upper part of the pelvis, Ave could 
not fail to expose the soft parts to the risk of contusion 
and (in consequence of the necessity of drawing more 
directly backward) unduly stretch and even lacerate the 
perineum. Hence it is now admitted by obstetricians, 
with few exceptions, that the second curve is essential 
before the complete descent of the head, although it is 
not absolutely so after this has taken place, 'fhc only 
circumstances under which a straight blade can possess 
any superiority are in certain cases of occipito-posterior 
position in which it is found necessary t<> rotate the head 
round a large extenl of the pelvis, when the circular 
sweep of a strongly-curved instrument might prove 
injurious. Such cases, however, are of rare occur- 
rence, and need in no way influence the general em- 
ployment of the pelvic curve. 

Ziegler^a Forceps, — The short forceps usually employed in Scotland is 
the invention of the late Dr. Ziegler (Fig. L59), and i- useful from the 




Denman's Short Forceps 



Fig. 1-39. 




474 



OBSTETRIC OPERATIONS. 



Fig. 160. 



facility with which the blades may be introduced in accurate apposition 
to each other — a point which in practice is of no little value. In gen- 
eral size and appearance it closely resembles Denman's forceps, but the 
fenestrum of the lower blade is continued down to the handle. In 
introducing, the lower blade is slipped over the handle of the other 
blade, already in situ, and thus it is guided with great certainty into a 
proper position, locking itself as it passes on. This instrument has the 
disadvantage of not having the second curve, but the facility of intro- 
duction has rendered it a great favorite with many who have been in the 
habit of employing it. 

The Long Forceps. — For cases in which the head is not on the peri- 
neum, or at least not quite low in the pelvis, a longer instrument is essen- 
tial. To meet this indication Smellie invented the long forceps, which, 
like the shorter instrument, has been very variously modified. The most 
perfect instrument of the kind employed in this country is that known 
as Simpson's forceps (Fig. 160), which combines many excellent points 
selected from the forceps of various obstetricians, as well as some original 
additions, and which, as a whole, has never been surpassed until Tarnier's 
or its modification was invented. The curved portions of the blades are 
6J inches long, the fenestrum measuring 1^ at its widest part. The 

extremities of the blades are 1 inch 
asunder when the handles are closed, 
and 3 inches at their widest part. The 
object of this somewhat unusual width 
is to lessen the compressing power of the 
instrument without in any way interfer- 
ing with its action as a tractor. The 
pelvic curve is less than in most long 
forceps, so as to admit of the rotation of 
the head, when necessary, without the 
risk of injuring the maternal structures. 
Between the curve of the blade and 
the lock is a straight portion or shank 
measuring 2-| inches, which, before 
joining the handle, is bent at right 
angles into a knee. This shank is a 
useful addition to all forceps, and is 
essential in the long forceps to ensure 
the junction of the blades beyond the 
parts of the mother, which might other- 
wise be caught in the lock and injured. 
The knees serve the purpose of pre- 
venting the blades from slipping from 
each other after they have been united. 
They also admit of one finger being 
introduced above the lock and used as 
an aid in traction — a provision which 
is made in some other varieties of long 
forceps by a semicircular bend in each shank. The handles, which in 
most British forceps are too small and smooth to afford a firm grasp, are 



Simpson's Forceps. 



THE FORCEPS. 475 

serrated at the edge and flattened from before backward, so as to fit the 
closed fist more accurately. At their extremities, near the lock, there 
are a pair of projecting rests, over which the fore and middle fingers 
may be passed in traction, and which greatly increase our power over 
the instrument. Although this and other varieties of the long forceps 
are specially constructed for application when the head is high in the 
pelvis, it answers quite as well as the short forceps — indeed, in most 
respects better — when the head has descended low down. It is a decided 
advantage for the practitioner to habituate himself to the use of one 
instrument, with the application and power of which he becomes thor- 
oughly familiar. It is a mere waste of space and money for him to 
encumber himself with a number of instruments of various shapes and 
sizes ; and he may be sure that a good pair of long forceps will be suit- 
able for every emergency and in any position of the head. 

Disadvantages of a Weak Instrument. — The chief argument against 
the use of such an instrument in simple cases is its great power. This, 
however, is entirely based on a misconception. The existence of power 
does not involve its use, and the stronger instrument can be employed 
with quite as much delicacy and gentleness as the weaker. The remarks 
of Dr. Hodge * on this point are extremely apposite and are well worthy 
of quotation. He says : " Certainly, no man ought to apply the forceps 
who has not sufficient discretion to use no more force than is absolutely 
requisite for safe delivery. If, therefore, there is more power at com- 
mand, he is not obliged to use it; while, on the contrary, if much* power 
be demanded, he can, within the bounds of prudence, exercise it by the 
long forceps, but with the short forceps his efforts might be unavailing. 
Moreover, in cases of difficulty, the short forceps being used, the prac- 
titioner would be forced to make great muscular efforts ; while with the 
long forceps, owing to the great leverage, such effort will be compara- 
tively trifling, and of course the whole force demanded can be much 
more delicately, and at the same time efficiently, applied, and with more 
safety to the tissues of the child and its parent." 

Continental Forceps. — The forceps usually employed on the Continent 
and in America differs considerably, both in appearance and construc- 
tion, from those in use in this country. As a rule, it is a larger and 
more powerful instrument, joined by a pivot or button joint, and it 
always possesses the second or pelvic curve. Of late years Simpson's 
forceps has been much employed in some parts of Germany. The chief 
objection to the continental instruments is their cumbrousness. This is 
chiefly in the handles, which in many of them are forged in a piece 
with the blades, the pari introduced within the maternal structures not 
being materially different from the corresponding part of the English 
instrument. 

T'iriiicr's Forceps. — The forceps invented by Prof. Tarnier ( Fig. L61) 
has recently attracted considerable attention. In this instrument trac- 
tion is not made on the handles by which the blade- arc introduced, ;i- 
in ordinary forceps, but <>n a supplementary handl< (a) subsequently 
attached to the blades near the lower opening of the fenestra (J>). The 
object claimed for this arrangement is thai less i'<>r<-r \- required in trao- 

1 System of Obstetrics, |>. '-'12. 



476 



OBSTETRIC OPERATIONS. 



tion, which can always, be made in the proper axis of the pelvis ; that 
the blades are not likely to slip ; and that rotation of the head is not 
interfered with. The handles of the forceps, moreover, guide the opera- 
tor to the direction in which he ought to pull, since all that is required 
is to keep the traction-rods parallel to them. This instrument, however, 
although theoretically perfect, is somewhat too complicated for gen- 
eral use. 

Simpson's Axis-Traction Forceps. — Professor Simpson of Edinburgh 
has invented a modification of Tarnier's instrument, which he calls the 



Fig. 161. 



Fig. 162. 





Tarnier's Forceps. 



Simpson's Axis-Traction Forceps. 
b. Traction handle, c, f. Line of traction. 



"axis-traction forceps" (Fig. 162). The supplementary handles are 
fixed to the blades, and the whole mechanism is much simpler than in 
Tarnier's forceps. Dr. Simpson reports very favorably of this forceps, 
and it is certainly well adapted for the object aimed at. For some years 
I have used it extensively, and have every reason to be satisfied with it, 
especially in the high forceps operation, in which it seems to me superior 
to any other instrument. 

Action of the Instrument — The forceps is generally said to act in 
three different ways : 

1st. As a tractor ; 

2d. As a lever ; 

3d. As a compressor. 

The Chief Use of the Forceps is as a Tractor. — It is more especially 
as a tractor that the instrument is of value, and it is used with the 
greatest advantage when it is employed merely to supplement the action 
of the uterus, which is insufficient of itself to effect delivery, or when, 
from some complication, it is necessary to complete labor with greater 
rapidity than can be accomplished by the unaided powers of nature. In 



THE FORCEPS. ■ 477 

most cases traction alone is sufficient ; but in order that it may act satis- 
factorily, and that the instrument may not slip, a proper construction 
of the forceps and a sufficient curvature of the blades are essential. The 
want of these is the radical fault of many of the short, straight instru- 
ments in common use, which have a tendency to slip during our efforts 
at extraction. 

As a Lever. — The forceps acts also as a lever, but this action has been 
greatly exaggerated. It is generally described as a lever of the first 
class, the power being at the handles, the fulcrum at the lock, and the 
weight at the extremities. There may possibly be some leverage power 
of this kind when the instrument is first introduced and the handles 
held so loosely that one blade is able to work on the other. But, as 
ordinarily used, the handles are held with a sufficiently firm grasp to 
prevent this movement, and then the two blades practically form a single 
instrument. 

Galabin, who has studied this subject in detail, points out 1 that — " 1. 
The lever is formed by both blades of the forceps and the foetal head 
united in one immovable mass. As soon as the blades begin to slip over 
the head the lever is decomposed, and the swaying movement ceases to 
have any mechanical advantage. 2. The power is applied to the handles 
in a slanting direction. The resistance or weight does not act at a point 
either between the former and the fulcrum or beyond the fulcrum, but 
at a point in a plane nearly at right angles to the line joining these two 
points, and its direction is a line perpendicular to that plane of the pel- 
vis in which the greatest section of the head is engaged ; that is to say, 
in the case of straight forceps nearly parallel to the handles. The lever 
formed does not, therefore, strictly speaking, belong to any one of the 
three orders into which levers are commonly divided. 3. The fulcrum 
is fixed partly by friction, partly by the combination of traction with 
oscillatory movements — in other words, by the power being directed in 
great measure downward and only slightly to one side." 

He further shows that the pendulum motion of the forceps is super- 
fluous in all ordinary forceps operations in which traction alone is amply 
sufficient for delivery, but that when the head is impacted and greal 
force is required for its extraction, a mechanical advantage may he gained 
from having recourse to an oscillatory movement, which should, how- 
ever, be very limited, and only continued if found to effect distinct 
advance of the head. 

As a Compressor. — Regarding the compressive power of (he instru- 
ment there has been much difference of opinion. There is no doubt 
that the forceps, especially some of the foreign instruments in which the 
points nearly approach each other, is capable of exerting considerable 
compression on the head. It is, however, extremely problematical if 
this action be of real value. It is to he borne in mind thai in cases of 
protracted Labor the head has been already moulded and compressed, and 
the bones have been made to overlap each other t«» their utmosi extent, 

by the sides of the pelvis. Wo can scarcely, therefore, exped to dimin- 
ish the head much more by the forceps without employing an amount of 

1 Galabin, "Action of Midwifery Forceps as ;i Lever," Obstetrical Journal, November, 

1876. 



478 OBSTETRIC OPERATIONS. 

force that will seriously endanger the life of the child. It is in cases of 
disproportion between the head and the pelvis, depending on slight 
antero-posterior contraction of the pelvic brim, that diminution of the 
child's head by compression would be most useful. Then, however, the 
pressure of the forceps is exerted on that portion of the head which lies 
in the most roomy diameter of the pelvis, where there is no want of 
space. If this pressure do not increase the opposite diameter, which is 
in apposition to the narrower portion of the pelvis, it can at least do 
nothing toward lessening it, and diminution of any other part of the 
child's head is not required. 

Dynamical Action of the Forceps. — -The mere introduction of the for- 
ceps sometimes excites increased uterine action through the reflex irri- 
tation induced by the presence of a foreign body in the vagina. This 
has been called the dynamical action of the forceps, but it cannot be 
looked upon in any other light than that of an occasional accidental 
result. 

The circumstances indicating the use of the forceps have been sepa- 
rately considered elsewhere, and to recapitulate them here would only 
lead to needless repetition. I shall therefore now merely describe the 
mode of using the instrument. 

Difference behveen the High and Loio Operations. — Before doing so it 
is well to repeat what has already been said as to the difference between 
what may be termed the high and low forceps operations. The appli- 
cation of the instrument when the head is low in the pelvis is extremely 
simple, and when there is no disproportion between the head and the 
pelvis, and some slight traction is alone required to supplement deficient 
expulsive power, the operation in the hands of any ordinary well-in- 
structed practitioner ought to be perfectly safe both to the mother and 
child. It is very different when the head is arrested at the brim or high 
in the pelvis. Then the applicatiou of the forceps is an operation requir- 
ing much dexterity for its proper performance, and must never be under- 
taken without anxious consideration. It is because these two classes of 
operations have been confused that the use of the instrument is regarded 
by many with such unreasonable dread. 

Preliminary Considerations. — Before attempting to introduce the for- 
ceps there are several points to which attention should be directed : 

1st. The membranes must, of course, be ruptured. 

2dly. For the safe and easy application of the instrument it is also 
advisable that the os sKould be fully dilated and the cervix retracted 
over the head. Still, these two points cannot be regarded, as many 
have laid down, as being sine qua non. Indeed, we are often compelled 
to use the instrument when, although the os is fully dilated, the rim of 
the cervix can be felt at some point of the contour of the head, espe- 
cially in cases in which the anterior lip is jammed between the head and 
the pubes. Provided clue care be taken to guard the cervical rim with 
the fingers of one hand as the instrument is slipped past it, there need 
be no fear of injury from this cause. If the os be not fully dilated, but 
is sufficiently open to admit of the passage of the forceps, the operation, 
under urgent circumstances, may be quite justifiable, but it must neces- 
sarily be a somewhat anxious one. 



THE FORCEPS. 479 

3dly. The position of the head should be accurately ascertained by 
means of the sutures and fontanelles. Unless this be done, the opera- 
tion will always be haphazard and unsatisfactory;, as the practitioner can 
never be in possession of accurate knowledge of the progress of the case. 
It may be that the occiput is directed backward, and, although that does 
not contraindicate the application of the forceps, it involves special pre- 
cautions being taken. 

4thly. The bladder and bowels should be emptied. 

Question of Administering Ancesthetics. — Before proceeding to operate 
the question of anaesthesia will arise. In any case likely to be difficult 
it is of the greatest assistance to have the patient completely under the 
influence of an anaesthetic to the surgical decree, so as to have her as still 
as possible ; but, whenever this is deemed necessary, another practitioner 
should undertake the responsibility of the administration. In simple 
cases I believe it is better to dispense with anaesthetics altogether — partly 
because they are apt to stop what pains there are, which is in itself a 
disadvantage, but chiefly because under partial anaesthesia the patient 
loses her self-control, is restless, and twists herself into awkward posi- 
tions, which give rise to the utmost difficulty and inconvenience in the 
use of the instrument. Moreover, if no anaesthetic be given the patient 
can assist the operator by placing herself in the most convenient attitude. 

Description of the Operation. — In describing the method of applying 
the forceps I shall assume that we have to do with the simpler variety 
of the operation, when the head is low in the pelvis. Subsequently I 
shall point out the peculiarities of the high operation. 

Position of the Patient. — As to the position of the patient, I believe 
there can be no doubt of the superiority of that which is usually adopted 
in this country. On the Continent and in America the forceps is always 
employed with the patient lying on her back — a position involving much 
needless exposure of the person and requiring more assistance from others. 
In certain cases of unusual difficulty the position on the back is of un- 
questionable utility, but we may at least commence the operation in the 
usual Avay, and subsequently turn the patient on her back if desirable. 

Importance of Suitable Position. — Much of the facility with which the 
blades are introduced depends on the patient's being properly placed. 
Hence, although it gives rise to a little more trouble at first, I believe 
that it is always best to pay particular attention to this point, whether 
the high or low forceps operation be about to be performed. The patient 
should be brought quite to the side of the bed, with her oates parallel to 
and projecting somewhat over its ah^v. The body should lie almost 
directly across the bed, and nearly at right angles to the hips, with the 
knees raised toward the abdomen (Fig. 163). In tin- way there is m> 
risk of the handle of the upper blade, when depressed in introduction, 
coining in contact with the bed. 

The blades should be warmed in tepid water, lubricated with cold 
cream or carbolic oil, and placed ready to hand. 

These preliminaries having been attended to, we proceed t<» the intro- 
duction of the blades, sitting by the side of the bed opposite the nates of 
the patient. 

Direction in which the Wade* ere to be Introduced. — The important 



480 OBSTETRIC OPERATIONS. 

question now arises, In what direction are the blades to be passed ? The 
almost universal rule in our standard works is, that they must be passed 
as nearly as possible over the child's ears, without any reference to the 
pelvic diameters. Hence, if the head have not made its turn, but is 
lying in one oblique diameter, the blades would require to be passed in 

Fig. 163. 



Position of Patient for Forceps Delivery, and Mode of Introducing Lower Blade. 

the opposite oblique diameter ; in short, the position of the forceps, as 
regards the pelvis, must vary according to the position of the head. 
Some have even laid down the rule that the forceps is contraindicated 
unless an ear can be felt — a rule that would very seriously limit its 
application, as in many cases in which it is urgently required it is a 
matter of great difficulty, and even impossibility, to feel the ear at all. 
It is admitted that in the high forceps operation the blades must be 
introduced in the transverse diameter of the pelvis, without relation to 
the position of the head. On the Continent it is generally recommended 
that this rule should be applied to all cases of forceps delivery alike, 
whether the head be high or low ; and I have now for many years 
adopted this plan, and passed the blades in all cases, whatever be the 
position of the head, in the transverse diameter of the pelvis, without 
any attempt to pass them over the bi-parietal diameter of the child's 
head. Dr. Barnes points out with great force that, do what Ave will and 
attempt as we may to pass the blades in relation to the child's head, they 
find their way to the sides of the pelvis, and that the marks of the fenes- 
tra on the head always show that it has been grasped by the brow and 
side of the occiput. Of the perfect correctness of this observation I have 
no doubt ; hence it is a needless element of complexity to endeavor to 
vary the position of the blades in each case, and one which only confuses 
the inexperienced practitioner and renders more difficult an operation 
which should be simplified as much as possible. While, therefore, it 
is of importance that the precise position of the head should be ascer- 



THE FORCEPS. 



481 



tained in order that we may have an intelligent notion of its progress, 
I do not think that it is essential as a guide to the introduction of the 
forceps. 

Method of Introducing the Lower Blade. — As a rule, the lower blade, 
lightly grasped between the tips of the index and middle fingers and 
thumb, should be introduced first. Poised in this way, we have perfect 
command over it, and can appreciate in a moment any obstacle to its 
passage. Two or more fingers of the left hand are introduced into the 
vagina and by the side of the head as a guide. The greatest care must 
be taken, if the cervix be within reach, that they are passed within it, so 
as to avoid the possibility of injury. 

Necessity of Gentleness in Passing the Instrument. — The handle of the 
instrument has to be elevated, and its point slid gently along the palmar 
surface of the guiding fingers until it touches the head (Fig. 163). At 
first the blade should be inserted in the axis of the outlet, but as it pro- 
gresses the handle must be depressed and carried backward. As it is 
pushed onward it is made to progress by a slight side-to-sicle motion, 
and it is of the utmost importance to bear in mind that the greatest gen- 
tleness must always be used. If any obstruction be felt, we are bound 
to withdraw the instrument partially or entirely, and attempt to manoeu- 
vre, not force, the point past it. As the blade is guided on in this way 
it is made to pass over the convexity of the head, the point being always 
kept slightly in contact with it, until it finally gains its proper position. 
When fully inserted the handle is drawn back toward the perineum and 

Fig. 164. 




Introduction of tli^ Upper Blade. 

given in charge to an assistant. The insertion must be carried on only 
in the intervals between the pains, and desisted from during their occur- 
rence; otherwise there would be a serious risk of injuring the son" parte 
of the mother. 

Introduction of the Upper Blade. — The second blade is passed directly 

31 



482 



OBSTETRIC OPERATIONS. 



opposite to the first, and is generally somewhat more difficult to intro- 
duce in consequence of the space occupied by the latter. It is passed 
along two fingers directly opposite the first blade, and with exactly the 
same precautions as to direction and introduction, except that at first its 
handle has to be depressed instead of elevated (Fig. 164). 

Locking of the Handles. — The handle which was in charge of the 
assistant is now laid hold of by the operator, and the tivo handles are 
drawn together. If the blades have been properly introduced, there 
should be no difficulty in locking ; but should we be unable to join 
them easily, we must withdraw one or other, either partially or entirely, 
and reintroduce it with the same precautions as before. We must also 
assure ourselves that no hairs nor any of the maternal structures are 
caught in the lock. 

Method of Traction. — When once the blades are locked we may com- 
mence our efforts at traction. To do this we lay hold of the handles 

Fig. 165. 




Forceps in Position : Traction in the Axis of the Brim, Downward and Backward. 

with the right hand, using only sufficient compression to give a firm 
grasp of the head and to keep the blades from slipping. The left hand 
may be advantageously used in assisting and supporting the right during 
our efforts at extraction, and at a late stage of the operation may be em- 
ployed in relaxing the perineum when stretched by the head of the child. 
Traction must always be made in reference to the pelvic axes, being at 
first backward toward the perineum (Fig. 165) in the direction of the 
axis of the brim, and as the head descends and the vertex protrudes 
through the vulva it must be changed to that of the outlet (Fig. 166). 
If the axis-traction forceps is used, it is to be borne in mind that trac- 
tion is to be made by the traction-handle only, the handles of the instru- 
ment itself being left untouched after they are locked and the traction- 



THE FORCEPS. 



483 



rods are united. By keeping these latter parallel to the handles of the 
forceps traction can always be made in the proper direction. We must 
extract only during the pains, and if these should be absent we must 
imitate them by acting at intervals. This is a point which deserves 
special attention, for there is no more common error than undue hurry 
in delivery. 

The only valid objection I know of against a more frequent resort to 
the forceps in lingering labor is that the sudden emptying of the uterus 
in the absence of pains may predispose to hemorrhage ; but it cannot be 
denied that it is one of some weight. However, if due care be taken to 
operate slowly, and to allow several minutes to elapse between each 
tractive effort, while at the same time uterine contractions be stimulated 
by pressure and support, this need not be considered a contraindication. 
Besides direct traction we may impart to the instrument a gentle waving 
motion from handle to handle, which brings into operation its power as 
a lever, but this must be done only to a very slight extent, and must 
always be subservient to direct traction. 

Descent of the Head. — Proceeding thus in a slow and cautious manner, 
carefully regulating the force employed according to the exigencies of 

Fig. 166. 







Last Stage of Extraction. The Bandies of the Forceps are being Gradually turned 
Upward toward the Mother's Abdomen. 

the case, we shall perceive that the head begins to descend ; and its prog- 
ress should be determined from time to time by the fingers of the un- 
employed hand. 

The Rotation from the Oblique Diameter. — When the head li<'- in the 
oblique diameter, as it descends, in consequence of its perfect adaptation 



484 OBSTETRIC OPERATIONS. 

to the pelvic cavity, it will turn into the antero-posterior diameter with- 
out any effort on the part of the operator, provided only that the trac- 
tion be sufficiently slow and gradual. As the head is about to emerge 
it is necessary to raise the handles toward the mother's abdomen. More 
than usual care is required to prevent laceration of the perineum, which 
is always much stretched (Fig. 166). If, as often happens, the pains 
have now increased, and the perineum be very thin and tense, it may 
even be desirable to remove the blades gently, and leave the case to be 
terminated by the natural powers ; but if due precautions are used this 
need not be necessary. 

The peculiarities of forceps delivery in occipito-posterior positions 
have already been discussed (p. 320), and need not be repeated. 

High Forceps Operations. — When the high forceps operation has been 
decided on, the passage of the blades will be found to be much more 
difficult from the height of the presenting part, the distance which they 
must pass, and in some cases from the mobility of the head interfering 
with their accurate adaptation. The general principles of introduction 
and of traction are, however, identical. If the operation be attempted 
before the head has entered the pelvic brim, it must be fixed, as much 
as possible, by abdominal pressure. In guiding the blades to the head 
special care must be taken to avoid any injury of the soft parts, especially 
if the cervix be not completely out of reach. For this j^urpose it may 
even be advisable to introduce the entire left hand as a guide, so as to 
avoid any possibility of injuring the cervix from not passing the instru- 
ment under its edge. 

Peculiar Method of Introducing the Blades. — Some authors advise 
that in such cases the blade should be introduced at first opposite the 
sacrum until the point approaches its promontory. It is then made to 
sweep round the pelvis, under the protecting fingers, till it reaches its 
proper position on the head. This plan is advocated by Ramsbotham, 
Hall Davis, and other eminent practical accoucheurs, and it is certainly 
of service in some cases of difficulty, especially when, from any reason, 
it is not possible to draw the nates over the edge of the bed, when the 
necessary depression of the handle of the upper blade is difficult to effect. 
It involves, however, a someAvhat complicated manoeuvre, and it is sel- 
dom that the blades cannot be readily introduced in the usual way. 

Necessity of Care in Locking. — In locking, the slightest approach to 
roughness must be carefully avoided, for the extremities of the blades 
are now within the cavity of the uterus, and serious injury might easily 
be inflicted. If difficulty be met with, rather than employ any force 
one of the blades should be withdrawn and reintroduced in a more favor- 
able direction. If the blades have shanks of sufficient length, there 
should be no risk of including the soft parts of the mother in the lock ; 
which in a badly-constructed instrument is an accident not unlikely to 
occur. 

Method of Traction. — After junction, traction must at first be alto- 
gether in the axis of the brim, and to effect this the handles must be 
pressed well backward toward the perineum. As the head descends it 
will probably take the usual turn of itself, without effort on the part of 
the operator, and the direction of the tractive force may be gradually 



THE FORCEPS. 485 

altered to that of the axis of the outlet. If the pains be strong and 
regular and there be no indication for immediate delivery, Ave may re- 
move the forceps after the head has descended upon the perineum, and 
leave the conclusion of the case to nature. This course may be especially 
advisable if the perineum and soft parts be unusually rigid, but generally 
it is better to terminate labor without removing the instrument. 

Possible Dangers of Forceps Delivery. — Before concluding this subject 
reference may be made to the possible dangers of the operation. I would 
here again insist on the importance of distinguishing between the high 
and low forceps operations, which have been so unfortunately and un- 
fairly confounded. Reasons have already been given for rejecting the 
statistics of the risks attending forceps delivery in the latter class of 
cases (p. 347). A formidable catalogue of dangers, both to mother and 
child, might easily be gathered from our standard works on obstetrics. 
Among the former, the principal- are lacerations of the uterus, vagina, 
and perineum ; rupture of varicose veins, giving rise to thrombus ; pel- 
vic abscess, from contusion of the soft parts ; subsequent inflammation 
of the uterus or peritoneum ; tearing asunder of the joints and symphyses ; 
and even fracture of the pelvic bones. A careful analysis of these, such 
as has been so well made by Drs. Hicks and Philips, 1 proves beyond 
doubt that the application of the instrument is not so much concerned in 
their production as the protraction of the labor and the neglect of the 
practitioner in not interfering sufficiently soon to prevent the occurrence 
of the evil consequences, afterward attributed to the operation itself. 
Many of these will be found to arise from the prolonged pressure on the 
soft parts within the pelvis, and the subsequent inflammation or slough- 
ing. To these causes may be referred with propriety most cases of 
vosi co-vaginal fistula (p. 439), peritonitis, and metritis following instru- 
mental labor. 

Some Depend on Ignorance on the Part of the Practitioner. — Lacera- 
tions and similar accidents may, however, result from an incautious use 
of the instrument. Slight lacerations of the mucous membrane of the 
vagina are probably far from Uncommon. But if these cases were closely 
examined, it would be found that the fault lay not in the instrument, 
but in the hand that used it. Either the blades were introduced without 
due regard to the axes of the pelvis, or they were pushed forward with 
force and violence, or an instrument was employed unsuitable to the 
case (such as a short straight forceps when the head was high in the 
pelvis), or undue haste and force in delivery were used. It would be 
manifestly unfair to lay the blame of such results upon the forceps, 
which in the hands of a more judicious and experienced practitioner 
would have effected the desired object with perfect safety. The instru- 
ment is doubtless unsafe in the hands of any one who does not under- 
stand its use, just as the scalpel or amputating-knife would be in the 
hands of a rash and inexperienced surgeon. The lesson to be learnt 
seems to be, clearly, nol thai the dangers should deter us from the use of 
the forceps, but that they should induce us to study more carefully the 
cases in which it is applicable and the method of using it with safety. 

Possible Risks to the Child. — The dangers to the child are, principally, 

1 ()h.<l. Trans., vol. xiii. 



486 OBSTETRIC OPERATIONS. 

lacerations of the integuments of the scalp and forehead ; contusion of 
the face ; partial but temporary paralysis of the face from pressure of a 
blade on the facial nerve ; depression or fracture of the cranial bones ; 
injury to the brain from undue pressure of the blades. These evils are 
of rare occurrence, and, when they do happen, generally result from 
improper management of the operation — such as undue compression, the 
use of improper instruments, or excessive and ill-directed efforts at trac- 
tion — and cannot, therefore, be considered as in any way contraindicating 
the use of the instrument. Many of the more common results, such as 
slight abrasions of the scalp or paralysis of the face, are transitory in 
their nature and of no real consequence. 

[ The Forceps in America. — Although the obstetrical forceps was first 
used in England, other countries in the march of improvement have 
made great changes, not only in the original forms, but in the manner 
of use ; and various shapes, as well as different positions of the woman 
in application, have become in a measure national. With the exception 
of having adopted almost exclusively the French and German dorsal 
decubitus in making use of the instrument, we have become in a measure 
eclectic in the selection of the latter ; medical schools, accoucheurs, and 
local obstetrical societies influencing students and the junior members of 
the profession to adopt the French, German, English, or American style, 
as the case may be, the forceps themselves bearing the names of the sev- 
eral inventors or compilers ; for some are a true compilation — the blade 
from one contriver ; fenestral openings, another ; pelvic curve, a third ; 
width, a fourth ; shanks, a fifth ; method of locking, a sixth ; etc. etc. 
For this reason the late Prof. Hodge named his forceps the eclectic, 
although in some respects entirely original, particularly in the long 
superimposed shanks — a great improvement for operating at the superior 
strait and avoiding the painful stretching of the posterior commissure of 
the vulva. Dr.* Hodge expended a great deal of thought and money in 
perfecting his forceps, and the various steps in the process were marked 
by a new form, until, from a heavy, clumsy instrument, he gradually 
evolved what was at one time regarded as a wonderful improvement 
upon the forceps of France and England. 

A contemporary of Prof. Hodge, the late Prof. David D. Davis of 
London, was equally anxious to perfect the instrument, and turned his 
attention especially to making the blades light, open, and to fit the sides 
of the foetal head so as to enable traction to be made without much pres- 
sure or leaving any mark on the child's scalp. There is a principle of 
mechanics involved in his instrument which he studied to perfect by 
moulding the blades so as to obtain considerable coaptating surface, and 
thus by increase of friction to avoid undue and dangerous pressure. 
The Davis blade soon began to effect changes in the form of American 
forceps, and by the addition of long handles and some alterations of 
shape, weight, and curve became a leading feature in those bearing the 
names of William Harris, Prof. Wallace of the Jefferson Medical Col- 
lege, Dr. Bethel, and Albert H. Smith, all of this city. The short Davis 
instrument was a great favorite with the late Prof. Meigs and Dr. Wil- 
liam Harris, both largely engaged in obstetrical practice as well as 
teaching ; and many a delicate woman with wasting forces was aided in 



THE FORCEPS. 487 

her delivery at their hands, and was surprised to find do mark on the 
baby's head, and that her own sufferings could be so gently and safely 
relieved. 

Although such was the estimation of the Davis blade, and still is in 
many parts of our country, it does not appear to have retained its popu- 
larity or been adopted, as its mechanical perfection would lead one who 
appreciates it to suppose it would have been. In Great Britain the 
favorite forms now in use are but a very slight improvement upon the 
forceps of a hundred years ago except in finish and material, the open 
fenestra? and bevelled blades of Davis being declined in favor of the 
looped fenestra? and flat-edged blades in use when he made his experi- 
ments and changes. This appears to have grown out of a practice which 
has been largely adopted in Germany, Great Britain, and many parts of 
the United States in applying the forceps to the foetal head, the blades 
being introduced at the sides of the pelvis, without much reference to the 
position which the head occupies. As compression is objected to, the 
blades are made long and widely separated (3J to 3-|- inches), and the 
handles short, so as not to allow of much leverage. As the blades do not 
fit the head, the mechanism of labor as taught by Hodge has been much 
simplified, as it is not necessary to learn all the oblique fittings of the 
fenestra? over the parietal protuberances or ears. Dr. Meigs used to tell the 
students that the forceps was the "child's instrument" and should be used 
as a tractor; and it was as a well-applied mechanical tractor that he advo- 
cated the use of the Davis blades against those of Siebold, Levret, Bau- 
delocque, and Haighton, employed generally in our country forty years 
ago. His language is not very complimentary to what he denominates 
by distinction "the mother's instrument" the form being better adapted 
for saving the woman than the foetus. 1 

At the present day we have two general orders of forceps in use in 
the United States, under each of which may be placed a vast number 
of special varieties which are simply changes upon one or the other gen- 
eral type according to the fancy of the inventor. At the head of one 
type may be placed the long forceps of Prof. Hodge, designed to be 
adapted to the sides of the child's head in all possible cases ; and of the 
other, those of Prof. Simpson of Edinburgh or their modification by 
Profs. Elliot and Bedford of New York, intended to he used a- trac- 
tors, and applied in reference to the sides of the mother's pelvis, rather 
than to those of the infant's head. 

Taking the long forceps of Levret and Baudelocque as improved and 
modified by Hodge, with the blades of Prof. Davis as ;i substitute, and 
handles of less curve than those of [lodge, and we have the Ion-- for- 
ceps of Prof. Ellerslie Wallace, late of the Jefferson Medical College, the 
most frequent choice of those who purchase forceps of the manufacturers 
in Philadelphia. Next in order are the instruments of Hodge, Davis, 
and Simpson, Elliot, Bedford, and a few others — in all about a dozen 
forms that vary in popularity. The improvement of the late Prof. Elliot 
upon the instrument of Simpson consists in narrowing and lengthening 
the shanks, widening somewhat the fenestra, elongating the blades, .'jiv- 
ing greater security against slipping in the handles, and gauging thedis- 

[' Obstetrics, p. 540.] 



488 



OBSTETRIC OPERATIONS. 



tance between the blades by a milled-head screw-stop in the end of the 
handles : the shanks and blades are an exact counterpart of the Miller 
forceps of England, which appeared about the same time (1858). 

The Hodge forceps was based in its contrivance upon the following 
points : 1. The instrument should be shaped to the contour of the foetal 
head, and have sufficient play to allow of compression where the pelvis 
is too narrow for the head to pass in its normal condition. 2. The blades 
should be so arranged in reference to the shanks and handles as to enable 
them to seize the head of the foetus in its bi-parietal diameter at the 
superior strait, and be drawn upon in the direction of the curve of the 



Fig. 167. 



Fig. 168. 



Fig. 169. 




Hodge Forceps. 



Wallace Forceps. 



Davis Forceps. 



pelvic canal until the delivery is complete. 3. The long forceps ought 
to be competent to act either at the superior strait of the pelvis, in its 
cavity or at its outlet, so as to avoid a multiplicity' of instruments and 
their attendant expense. And, 4. The instrument should not cut the 
scalp of the child if properly adjusted, or injure the soft parts of the 
mother. 

It would be folly to claim that all this could or has been accom- 
plished, as there must necessarily be exceptional cases in all the points 
given ; hence the contrivance of the forceps of Tarnier and Cleemann for 



THE FORCEPS. 489 

certain presentations above the superior strait, and the long and short con- 
vertible instruments of a few inventors. There are many cases of labor 
in the higher walks of life where, although there is no obstruction, still 
the women require manual or instrumental assistance, as they cannot 
deliver themselves for want of sufficient contractile muscular force. Such 
women require that the forceps used should be easily introduced — should 
act simply as tractors, control the movement of the fcetal head by being 
well fitted to its shape, and leave no effect upon the scalp or vulva. 
Although these requisites may be filled by the Hodge instrument, it is 
this class of cases that has demanded a lighter and more roomy pair of 
forceps, such as that devised by Davis. 

As the teaching of the Jefferson Medical College under Dr. Meigs 
favored, as we have stated, the forceps of Davis, so his successor, Prof. 
Wallace, in carrying out in a measure the same views, combined the 
blades of the Davis pattern with the long handles of Hodge in con- 
triving what is known as the " Wallace forceps" now so much in use 
by the large number of graduates of this school. As compared with 
the Hodge instrument, it is 1 inch shorter (15 inches against 16); the 
blades are of the same length (6 inches) ; the fenestra? are more open ; 
the shanks, are only half the length, giving a much greater compressing 
power ; and the handles are of the same measurement from pivot to 
hooks. Both have the Siebold lock, over which we believe the broad- 
topped button and notch to possess some advantages ; and the Wallace 
is somewhat heavier than the Hodge, which should weigh 17 ounces. 

The short Davis instrument made for Prof. Meigs under direction of 
the inventor weighed lOf ounces and measured 12 inches in length ; 
fenestras, 5 inches long, 2 inches wide ; blades separated 2 J inches ; 
handles, 4J inches to lock, which was of the Smellie or English pat- 
tern. A recently-purchased pair in possession of the editor is 13 J- 
inches long, with 5-inch handles, a button lock, 2-inch close-set shanks, 
and 6-J-inch blades. I believe the changes are decided improvements, 
especially the lock and elongated handles. It has answered admirably 
in adynamic cases, requiring only a few pounds of tractile assistance. 
The Davis blades have been added to long handles, and the whole 
made of steel and marvellously light, at the special request of a few 
accoucheurs, who wished them to aid in some cases of arresl at the 
perineum. 

The late Prof. George T. Elliot of New York, who received much 
of his practical obstetrical training in the Dublin Lying-in Hospital, 
imbibed the teachings of the English school, and became impressed with 
the value of the system as taught by Simpson, upon the principle of 
whose forceps, modelled somewhat after that of the late Prof. Gunning 
S. Bedford of New York, he in 1858 presented t<> the medical profes- 
sion the instrument that bears his name. The forceps of Prof. Bedford 
has a traction-ring on each side where the Elliot ha- a eornu, ha- a but- 
ton joint, instead of a Smellie, has no screw-stop, and has diverging 
instead of superimposed shanks. These points have generally been con- 
sidered as improvements, and hence the Klliot has taken precedence in 
Large measure over the Bedford instrument in New York, the two being 
the leading forceps in demand. The instrument of White ..!' Buffalo i- 



490 



OBSTETRIC OPERATIONS. 



Fig. 170. 



Fig. 171. 



perhaps next, and then Hodge's. But few of Prof. Wallace's forceps, 
long the leading instrument in Philadelphia sales, are ordered. The 
White is a long forceps, a compound of the Elliot blade, long super- 
imposed shanks of Hoclge, Siebold lock, and short corrugated, steel 
handles bowed out like dental forceps and ending in thin blunt hooks. 
The Sawyer and Simpson short forceps are said to be about equally 
in demand in New York. The former is almost unknown in Phila- 
delphia, and but comparatively 

few of the Simpson are asked 

for, although the system of their 

application has several advocates 

in this city. 

The Saivyer Forceps. — This is 

the lightest of all the varieties of 

the short forceps, weighing but 5 

ounces, and measuring 9f- inches 

in length ; the handle being 3 

inches, shank 



blade-curve 5 \. 



1^, and chord of 
The blades are 1^ 




Sawyer Forceps. 



inches wide, with oval fenestra? |- 

inch wide, and separated 2-f- inches 

at their widest part and |- inch 

at the tips. This instrument was 

invented eight years ago by Prof. 

Edw. Warren Sawyer of Rush 

Medical College, Chicago, and has 

been highly commended by Prof. 

Byford' and others. The forceps 

has the blades of Davis, superim- 
posed shanks of Hodge, and lock 

of Smellie, with hard-rubber plates 

moulded hot upon the handles. 

The several parts have been some- 
what modified, the object being to secure a tractor for 

cases of deficient expulsive force where the foetal head 

is low in the pelvis. 

Professor Sawyer says : " In the labors to which my 
forceps is applicable it is not necessary for the operator's body to be in 
line with the pelvic axis. My mode of procedure is the following : 
The woman is placed upon her back and drawn to the edge of the bed ; 
the outside leg is now flexed ; beneath this flexed extremity and the 
bed-covering I apply the forceps — often using but one hand in the 
operation. ^ When the instrument is locked, I grasp the handle in such 
a manner that the palm of the hand looks upward ; one hook then 
rests naturally upon the extensor surface of the first phalanx of the 
index finger, while the other hook rests upon a corresponding part of 
the thumb. When thus adjusted, I lift the head from the pelvic outlet, 
at the same time invoking the pendulum movement if desired. At this 
moment the advantage of the hooked handle is very apparent to the 
operator." .... "All practitioners must have often felt, during 



Elliot Forceps. 



THE FORCEPS. 



491 



the last moments of labor, Avhen the uterus and the mother seemed fa- 
tigued, the need of a little help to the expansive powers. The ordinary 
instruments are too formidable to be used at the last moment, and it is 
then that this little forceps is useful." 

I have given the names and characters of the various forceps most in 
use in Xew York and Philadelphia, and by the large number of gradu- 
ates of their respective schools, as shown by their preferences in select- 
ing instruments of the leading makers of the two cities. The mechan- 
ism of instrumental delivery is much simplified by applying the forceps 
to whatever parts of the foetal head may be opposite the sides of the 
pelvis ; but it is very questionable whether it is the scientific method 
or the safer for the child. AVith one blade over the side of the occiput, 
and the other over that of the forehead — which is the manner of seizure 
in oblique positions of the vertex — we certainly have not a very secure 

Fig. 172. 





N 



Application of the Forceps al the Inferior strait. 

hold and run some risk of injury to the fetus. The advocates of this 
system claim that they use no compression, only a simple traction ; 
which may be true in one sense, but amounts to the same in effect, i Ise 
how could Dr. Elliot, by traction with great force, straighten out ooe 



492 OBSTETRIC OPERATIONS. 

of the blades of his Simpson forceps, as related in the New York Journ. 
of Medicine for September, 1858, p. 161, in the paper which he pre- 
sented describing his new forceps and a number of cases in which he 
had tested them? It makes but little difference whether we compress 
the head before we begin to pull, or pull so as to wedge the head 
between the blades, and thus compress it, except as to the difference of 
fit in the two instances ; the adjusted and even pressure being the less 
likely to injure the foetus. I have always believed that the forceps 
should fit the head, and- that the student should be taught how to 
accomplish it correctly in the various positions of the foetus. If the 
student has a mechanical turn of mind, a delicate sense of touch, and a 
clear head, he will soon learn ; if he is not a mechanic, he will be forced 
to adopt a more simple method of delivery. In a large city there are 
but few first-class obstetrical manipulators as a general rule, and they 
are usually well known as such, for the reason that but few have all the 
requisites to enable them to achieve notoriety ; and yet there are hun- 
dreds who can deliver a woman with forceps moderately well. To one 
the mechanism of Hodge is a simple matter and soon mastered; to 
another it is a useless complication, and he prefers the more simple sys- 
tem. Hence the great differences between obstetricians as to the best 
instrument and the best method of application. Some of the vast array 
of patterns have decided merit and display much mechanical skill, while 
others serve only to amuse the educated examiner. One obstetrician, 
after the manner of Elliot, uses a variety of forceps one after another in 
the same case, and pulls with great force, while another confines his 
work almost to one instrument, adjusts it easily, pulls moderately, and 
seldom fails. There are no doubt exceptions, but certainly the most 
delicate manipulators we have seen, believed in and practised the teach- 
ings of Hodge and Meigs. There may be cases where it might be well 
to practise the method of Simpson, as is done occasionally by some of 
our leading practitioners, but we cannot see why his plan of delivery 
should be exclusively used on any mode of scientific reasoning. 

I present a series of plates in illustration of the American method of 
delivery with the forceps, the position, as will be seen, being that of 
France and Germany — on the back. When it is decided to use the for- 
ceps, in almost all cases in the United States the patient is brought to 
the edge of the bed on her back, with her nates close to the edge, her 
feet on two chairs, and her knees widely separated, as in the plate above. 
The patient is covered with a sheet, or heavier covering if in winter, 
and there is no necessity of exposure, as the whole manipulation may 
be done by the sense of touch. The position is by far the most conveni- 
ent for the obstetrician, and enables him much more easily to keep in 
his mind all the anatomical relations of the foetus and .pelvis than when 
in the English decubitus. We study the anatomy with the subject on 
the back, and the mechanism of labor in front of the pelvis or manikin ; 
then why complicate matters by a change of position, which, to say the 
least, is a very awkward one, particularly in introducing the long for- 
ceps, setting it according to the instructions of Hodge, and carrying it 
forward between the thighs as the head emerges ? I have used the short 
forceps in an exhausted case with the woman on her side, but found it 



THE FORCEPS. 



493 



much less convenient for the various movements, although I soon deliv- 
ered the foetus. As to the question of exposure, there is less in appear- 
ance than, in fact, in the English position, in many cases. If the patient 
and nurse are fastidious and careful during the use of the forceps, the 
accoucheur can manage without his eyes in a large proportion of cases ; 
but the fault of exposure lies more frequently in the temporary reckless 
indifference begotten of pain and suffering in the woman, than in any 
act of the accoucheur if inclined to spare the feelings of his patient as 
much as possible. 

The long forceps, with its pelvic curve, was specially designed for use 
at the superior strait of the pelvis, the curve of the blades, as in the 

Fig. 173. 




Application of the Forceps with the Head at the superior strait, the heft Blade held in Place by 

an Assistant. 

Davis instrument modified by Wallace, being intended to correspond 
with the direction of the occipito-mental diameter of the foetal head. 
The long superimposed shank- of several varieties "i" the long forceps 



494 



OBSTETRIC OPERATIONS. 



will here be found valuable, as the lock is not introduced or the posterior 
commissure of the vulva widely stretched. If the head is entirely above 
the strait, the line of the blades must be changed correspondingly, in 
order to apply them properly and keep the line of traction within the 



Fig. 17 




Direction of the Forceps as the Head is being Delivered . 

coccyx ; and even then, to draw in the proper direction, the left hand 
must act at first in a backward direction from the lock, while the right 
brings the handles downward, forward, and then upward ; both hands 
describing a curve, but that of the right being much the greater. The 
peculiar forceps of Tarnier or of Cleemann, being designed to meet this 
form of exigency, may be brought into requisition. These both have 
the blades of Davis. 

In latter years it has become much more common than formerly to 
introduce the forceps into the uterus before it is fully dilated, in conse- 
quence of the success claimed for the plan as carried out in the Dublin 
Lying-in Hospital. As this should never be done where the os is not 
readily dilatable, and requires much skill in execution, it is not safe to 
recommend its general adoption in cases of delay in private practice. 

The forceps should not be introduced with any force, but the left blade 
should be slid in gently, and with a spiral motion, and then the right, 
care being taken that they should also lock without force, which they 
will do if properly adjusted. Traction is to be exerted slowly and dur- 



THE VECTIS.—THE FILLET. 495 

ing a pain, the whole movement being made to correspond with the 
natural as closely as possible. 

As the foetal head comes under the arch of the pnbes the handles of 
the forceps must rise more and more from the bed, until at last they are 
over the abdomen as the head emerges from the perineum. This last 
movement of instrumental delivery should be a very slow one, for fear 
of rupture. It has been proposed to remove the blades before delivery 
is complete ; but there is no occasion for this if the forceps is applied to 
the sides of the head over the parietal protuberances, as, where these 
protrude and the blades are flat and thin, there is very little additional 
space required. With such instruments as the old Levret, Baudelocque, 
and Rohrer forceps, with looped or kite-shaped fenestras and thick edges, 
this was a much more imperative direction than with the better instru- 
ments of the present day. With a Sawyer forceps the perineum ought 
to be safer and under better control than without. When the perineum 
is thought to be in danger, the process of distension should be retarded 
through two or three pains, or even more if required, instead of draw- 
ing the head through at once. 

After the head is delivered, if the cord is not around the neck, and 
therefore in danger from pressure, the body should be allowed to remain 
until the uterus has well contracted upon it, for fear of hemorrhage after 
delivery from uterine inertia. — Ed.] 



CHAPTER IV. 

THE VECTIS.—THE FILLET. 

The Vectis. — In connection with the subject of instrumental delivery 
it is essential to say something of the use of the vectis. on account of 
the value which was formerly ascribed to it, which was at one time so 
great in this country that it became the favorite instrument in the 
metropolis; Denman saying of it that even those who employed the 
forceps were "very willing to admit the equal, if not superior, utility 
and convenience of the vectis." Even at the present day there are prac- 
titioners of no small experience who believe it to be of occasional great 
utility, and use it in preference to the forceps in cases in which slight 
assistance only is required. In spite, however, of occasional attempts 
to recommend it- use, the instrument has fallen into disfavor, and may 
be said to be practically obsolete. 

Nature of the Instrument, — The vectis, in it- most approved form, 
consists of a single blade, not unlike that of a short straight forceps, 
attached to a wooden handle. A variety of modification- exists in its 
shape and size. The handle has been occasionally manufactured, for the 
convenience of carriage, with a hinge close to the commencement of the 



496 OBSTETRIC OPERATIONS. 

blade (Fig. 175), or with a screw at the point where the handle and 
blade join. The power of the instrument and the facility of introduc- 
tion depend very much on the amount of curvature of the blade. If 
this be decided, a firmer hold of the head is taken and 
Fig. 175. greater tractive force is obtained, but the difficulty of intro- 
duction is increased. 

The Vectis is Used either as a Lever or a Tractor. — When 
employed in the former way the fulcrum is intended to be 
the hand of the operator ; but the risk of using the mater- 
nal structures as a point d'appui, and the inevitable danger 
of contusion and laceration which must follow, constitute 
one of the chief objections to the operation. Its value as 
a tractor must always be limited and quite inferior to that 
of the forceps, while it is as difficult to introduce and man- 
ipulate. 

Cases in which it is Applicable. — The vectis has been 
recommended in cases in which the low forceps operation 
is suitable, provided the pains have not entirely ceased. 
There is no doubt that it may be quite capable of overcom- 
ing a slight impediment to the passage of the head. It is 
Hinged Handle, applied over various parts of the head, most commonly 
over the occiput, in the same manner and with the same 
precautions as one blade of the forceps. Dr. Eamsbotham says, " We 
shall find it necessary to apply it to different parts of the cranium, and 
perhaps the face also, successively, in order to relieve the head from its 
fixed condition and favor its descent. " Such an operation obviously 
requires quite as much dexterity as the application of the forceps ; while, 
if we bear in mind its comparatively slight power and the risk of 
injury to the maternal structures, we must admit that the disuse of the 
instrument in modern practice is amply justified. 

Is Sometimes of Value in Correcting Mcdpositions of the Head. — The 
vectis may, however, find a useful application when employed to rectify 
malpositions, especially in certain occipito-posterior presentations. This 
action of the instrument has already been considered (p. 320), and under 
such circumstances it may prove of service where the forceps is inapplic- 
able. When so employed it is passed carefully over the occiput, and, 
while the maternal structures are guarded from injury, downward trac- 
tion is made during the continuance of a pain. So used, its application 
is perfectly simple and free from danger, and for this purpose it may be 
retained as part of the obstetric armamentarium. 

The Fillet. — The fillet is the oldest of obstetric instruments, having 
been frequently employed before the invention of the forceps, and even 
in the time of Smellie it was much used in the metropolis. It has since 
completely fallen out of favor as a scientific instrument, although its use 
is every now and again advocated ; and it is certainly a favorite instru- 
ment with some practitioners. This is to be explained by the apparent 
simplicity of the operation and the fact that it can generally be per- 
formed without the knowledge of the patient. The latter, however, is 
one strong reason why it should not be used. 

Nature of the Instrument — The fillet consists, in its most improved 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 497 



Fig. 17b. 



form (that which is recommended by Dr. Eardley AVilmot, 1 Fig. 176), 
of a slip of whalebone fixed into a handle composed of two separate 
halves, which join into one. The whalebone 
loop is slipped over either the occiput or face, 
and traction used at the handle. 

Objections to its Use. — When applied over 
the face after the head has rotated it would 
probably do no harm, but if it were so placed 
when the head was high in the pelvis, traction 
would necessarily produce extension of the 
chin before the proper time, and would thus 
interfere with the natural mechanism of de- 
livery. If placed over the occiput, it is im- 
possible to make traction in the direction of 
the pelvic axes, as the instrument will then 
infallibly slip. If traction be made in any 
other direction, there must be a risk of injur- 



ing the maternal structures or of changing 



? : > 



"3 



the position of the head. Hence there is 
every reason for discarding the fillet as a trac- 
tor or as a substitute for the forceps, even in 
the simplest cases. 

Its Use in Certain Malpositions of the Head. 
— It is quite possible that it may find a use- 
ful application in certain cases in which the 
vectis may also be used — viz. as a rectifier of malposition ; and from 
the comparative facility of its introduction it would probably be the 
preferable instrument of the two. 




<o 



u^'' 



Wilmot's Fillet. 



CHAPTER V. 



OPERATIONS INVOLVING DESTRUCTION OF THE F<ETUS. 



Operations involving the destruction and mutilation of the child 
were among the firsl practised in midwifery. Craniotomy was evidently 
known in the time of Hippocrates, as he mentions a mode of extracting 
the head by means of hooks. Celsus describes a similar operation, and 
was acquainted with the manner of extracting the foetus in transverse 
presentations by decapitation. Similar procedures were also practised 
and described by Act ins and others among the ancient writers. The 
physicians • of the Arabian school qo1 only employed perforators for 
opening the head, bul were acquainted with instruments for compressing 
and extracting it. 

Religious Objections to Craniotomy. — Until the end of the seventeenth 
1 Obst. ZVtins., vol. xv. 

32 



498 OBSTETRIC OPERATIONS. 

century this class of operation was not considered justifiable in the case 
of living children ; it then came to be discussed whether the life of the 
child might not be sacrificed to save that of the mother. It was author- 
itatively ruled by the Theological Faculty of Paris that the destruction 
of the child in any case was mortal sin : " Si Ton ne peut tirer l'enfant 
sans le teur, on ne peut sans peche mortel le tirer." This dictum of the 
Roman Church had great influence on continental midwifery, more espe- 
cially in France, where, up to a recent date, the leading obstetricians 
considered craniotomy to be only justifiable when the death of the foetus 
had been positively ascertained. Even at the present day there are not 
wanting practitioners who in their praiseworthy objection to the destruc- 
tion of a living child counsel delay until the child has died — a practice 
thoroughly illogical, and only sparing the operator's feelings at the cost 
of greatly-increased risk to the mother. In England the safety of the 
child has always been considered subservient to that of the mother ; and 
it has been admitted that in every case in which the extraction of a 
living foetus by any of the ordinary means is impossible its mutilation 
is perfectly justifiable. 

Its Unjustifiable Frequency. — It must be admitted that the frequency 
with which craniotomy has been performed in this country constitutes a 
great blot on British midwifery. During the mastership of Dr. Labbat 
at the Rotunda Hospital the forceps was never once applied in 21,867 
labors. Even in the time of Clarke and Collins, when its frequency was 
much diminished, craniotomy was performed three or four times as often 
as forceps delivery. These figures indicate a destruction of foetal life 
which we cannot look back to without a shudder, and which, it is to be 
feared, justify the reproaches which our continental brethren have cast 
upon our practice. Fortunately, professional opinion has now com- 
pletely recognized the sacred duty of saving the infant's life whenever 
it is practicable to do so ; and British obstetricians now teach, as care- 
fully as those of any other nation, the imperative necessity of using 
every endeavor to avoid the destruction of the foetus. 

Divisions of the Subject. — The operation now under consideration may 
be necessary — 1st, when the head requires either to be simply perforated 
or afterward more completely broken up and extracted — an operation 
which has received various names, but is generally known in this coun- 
try as craniotomy, and which may or may not require to be followed 
by further diminution of the trunk. 2dly, when the arm presents and 
turning is impossible. This necessitates one of two procedures — decap- 
itation -with, the separate extraction of the body and head, or evisceration. 
In both classes of cases similar instruments are employed, and those 
generally in use at the present time may be first briefly described. 

Description of Instruments Employed. — 1. Perforator. — The object of 
the perforator is to pierce the skull of the child, so as to admit of the 
brain being broken up and the consequent collapse and diminution in 
size of the cranium. The perforator invented byDenman or some mod- 
ification of it has been principally employed. It requires the handles to 
be separated in order to open the blades, and this cannot be done by the 
operator himself. This difficulty is overcome in the modification of 
Naegele's perforator used in Edinburgh, in which the handles are so 



OPERATIONS INVOLVING DESTRUCTION OF F(ETUS. 499 

constructed that they open the points when pressed together, and are 
separated by a steel rod, with a joint at its centre to prevent their open- 

Fig. 177. Fig. 178. Fig. 179. 




Figs. 180,181. 



Various Forms of Perforators. 

ing too soon. By this arrangement the instrument can be manipulated 
by one hand only. The sharp-pointed portion has an external cutting 
edge, with projecting shoulders at its base to prevent its 
penetrating too far into the cranium. Many modifica- 
tions of these arrangements have since been contrived 
( Figs. 177, 178, 179). In some parts of the Continent 
a perforator is used constructed on the principle of the 
trephine; but this is vastly more difficult to work, and 
has the great disadvantage of simply boring a hole in 
the -hull, instead of splitting it up, as is done by the 
sharp-pointed instrument. 

The instruments for extraction are the crotchet and 
craniotomy forceps. 

( 'rofrhrts and Craniotomy Forceps. — The crotchet is 
a sharp-pointed hook of highly-tempered steel, which 
can be fixed on some portion of the skull, either inter- 
nal or external, traction being made by the handle. 
The shank of the instrument is either straight or 
curved (Figs. ISO and 181), the latter being preferable, 
and it is either attached to a wooden handle or forged 
in a single piece of metal. A modification of this in- 
strument is known as Oldham's vertebral hook. It con- 
sists of a slender hook-, measuring, with it- handle, 13 
inches in length, which is passed through th<' foramen 
magnum and fixed in the vertebral canal, -<> a- t<> 
secure a firm hold for traction. All forms of crotchets 
are open to the serious objection of being Liable t" -lip 
or breakthrough the hone to which they are fixed, so wounding eitto 



%J 



500 



OBSTETRIC OPERATIONS. 



Fig. 183. 



Fig. 182. 



the soft parts of the mother or the fingers of the operator placed as a 
guard. Hence they are discountenanced by most recent writers, and 
may with propriety be regarded as obsolete instruments. 

Craniotomy Forceps are Preferable for Extraction. — Their place as 
tractors is well supplied by the more modern craniotomy forceps (Fig. 
182). These are intended to lay hold of the skull, one blade being 
introduced within the cranium, the other externally, and when a firm 
grasp has been obtained downward traction is made. A second object 
it fulfils is to break away and remove portions of the skull when 
perforation and traction alone are insufficient to effect delivery. 
Many forms of craniotomy forceps are in use — some armed with 
formidable teeth ; others, of simpler construction, depending on their 
roughened and serrated internal surfaces for firmness of grasp. For 
general use there is no better instrument than the cranioclast of Sir 

James Simpson (Fig. 183), which ad- 
mirably fulfils both these indications. 
It consists of two separate blades fast- 
ened by a button joint. The extrem- 
ities of the blades are of a duck-billed 
shape, and are sufficiently curved to 
allow of a firm grasp of the skull 
being taken : the upper blade is deep- 
ly grooved to allow the lower to sink 
into it, and this gives the instrument 
great power in fracturing the cranial 
bones when that is found to be neces- 
sary. It need not, however, be em- 
ployed for the latter purpose, and, the 
blades being serrated on their under 
surface, form as perfect a pair of cra- 
niotomy forceps as any in ordinary 
use. Provided with it, we are spared 
the necessity of procuring a number 
of instruments for extraction. 

Cephalotribe, — Amongst modern im- 
provements in midwifery there are few which have led to more discus- 
sion than the use of the cephalotribe. This instrument, originally in- 
vented by Baudelocque, was long employed on the Continent before it 
was used in this country, the prejudice against it being no doubt due to 
its formidable size and appearance. Of late years many of our leading 
obstetricians have used it in preference either to the crotchet or crani- 
otomy forceps, and have materially modified and improved its construc- 
tion, so that the most objectionable features of the older instruments are 
now entirely removed. 

Object of the Instrument— The cephalotribe consists of two powerful 
solid blades, which are applied to the head after perforation and ap- 
proximated by means of a screw so as to crush the cranial bones, and 
after this it may be also used for extraction. The peculiar value of 
the instrument is that when properly applied it crushes the firm basis 
of the skull, which is left untouched by craniotomy ; or, if it does not, 




Craniotomy Forceps. 



Simpson's Cranio- 
clast. 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 501 



Fig. 184. 



it at least causes the base to turn edgeways within the blades, so as to 
be in a more favorable position for extraction. Another and specially 
valuable property is that it crushes the bones within the scalp, which 
forms a most efficient protective covering to their sharp edges. In this 
way one of the principal dangers of craniotomy — the wounding of the 
maternal passages by spiculse of bone — is entirely avoided. 

Some Obstetricians Object to Using it as. a Tractor. — The omphalotribe, 
therefore, acts in two ways — as a crusher and as a tractor. Some obstet- 
ricians believe the former to be its more important use, and even main- 
tain that the cephalotribe is unsuited for traction. This view is specially 
maintained by Pajot, who teaches that after the size of the skull has 
been diminished by repeated crushings its expulsion should be left to 
the natural powers. There are some grounds for believing that in the 
greater degrees of obstruction the tractile power of the instrument should 
not be called into use ; but in the large majority of cases the facility 
with which the crushed head may be withdrawn by it constitutes one of 
its chief claims to the attention of the obstetrician. Xo one who has 
used it in this way, and experienced the rapid and easy manner in which 
it accomplishes delivery, can have any doubt on this point. 

Its Value. — There is every reason to believe that cephalotripsy will be 
much extended in this country, and that 
it will be considered, as I believe it un- 
questionably deserves to be, the ordinary 
operation in cases requiring destruction 
of the fetus. The comparative merits 
of cephalotripsy and craniotomy will be 
sul Hequently considered. 

Description of the Instrument. — The 
most perfect cephalotribe is probably that 
known as Braxton Hicks' (Fig. 184), 
which is a modification of Simpson's. 
It is not of unwieldy size, but sufficiently 
powerful for any case, and not extrava- 
gant in price. The blades have a slight 
pelvic curve, which materially facilitates 
their introduction, yet not sufficiently 
marked to interfere with their being 
slightly rotated after application. Dr. 
Kidd of Dublin prefers a straight blade, 
while Dr. Matthews Duncan thinks it 
better to nse a somewhat bulkier instru- 
ment, modelled on the type of the conti- 
nental cephalotribes. The principle of ac- 
tion of all these is identical, and their differ- 
ences are not of very material importance. 

Section of the Skull by the Fora vps 
Saw or Ecraseur. — Another mode of 
diminishing the foetal skull is by remov- 
ing it in sections. The object is aimed 
at in the forceps saw of Van Huevel, Bicks' cephalotribe. 




502 OBSTETRIC OPERATIONS. 

which consists of two large blades not unlike those of the cephalotribe 
in appearance. Within these there is a complicated mechanism working 
a chain-saw from below upward, which cuts through the foetal skull ; 
the separated portions are subsequently withdrawn piecemeal. This 
instrument is highly spoken of by the Belgian obstetricians, who believe 
that it affords by far the safest and most effectual way of reducing the 
bulk of the foetal skull. In this country it is practically unknown, 
and, although it must be admitted to be theoretically excellent, the com- 
plexity and cost of the apparatus have always stood in the way of its 
being used. 

Dr. Barnes has suggested that the same results may be obtained by 
dividing the head with a strong wire 6craseur. So far as I know, this 
suggestion has never yet been carried out in practice, not even by himself, 
and therefore it is not possible to say much about it. I should imagine, 
however, that there would be considerable difficulty in satisfactorily 
passing the loop of wire over the skull in a pelvis in which there is any 
well-marked deformity. 

Cases Requiring Craniotomy. — The most common cause for which 
craniotomy or cephalotripsy is performed is a want of proper proportion 
between the head and the maternal passages. This may arise from a 
variety of causes. The most important, and that most often necessitating 
the oj^eration, is osseous deformity. This may exist either in the brim, 
cavity, or outlet, and it is most often met with in the antero-posterior 
diameter of the brim. Obstetric authorities differ considerably as to the 
precise amount of contraction which will prevent the passage of a living 
child at term. Thus, Clarke and Burns believe that a living child can- 
not pass through a pelvis in which the antero-posterior diameter at the 
brim is less than 3^ inches ; Bamsbotham fixes the limit at 3 inches, and 
Osborne and Hamilton at 2|- inches. The latter is the extreme limit at 
which the birth of a living child is possible ; but there can be no doubt 
that under favorable circumstances it may be possible to draw the foetus, 
after turning, through a pelvis of that size. The opposite limit of the 
operation is still more open to discussion. Various authorities have 
considered it quite possible to draw a mutilated foetus through a pelvis 
in which the antero-posterior diameter does not exceed 1^ inches, and, 
indeed, have succeeded in doing so. But then there must be a fair 
amount of space in the transverse diameter of the pelvis to admit of the 
necessary manipulations. If there be a clear space here of 3 inches and 
upward, it is no doubt possible to deliver per vias naturales; but in such 
extreme deformities the difficulties are so great, and the bruising of the 
maternal structures so extensive, that it becomes an operation of the 
greatest possible severity, with results nearly as unfavorable to the mother 
as the Csesarean section. Hence some continental authorities have not 
scrupled to prefer the latter operation in the worst forms of pelvic 
deformity. The rule in English practice always has been that crani- 
otomy must be performed whenever it is practicable ; and there can be 
no doubt that it is the right one. 

Limits of the Operation. — Between from 2| to 3 inches antero-posterior 
diameter in one direction, 1|- inches in the other, may be said to be the 
limits of craniotomy, provided, in the latter case, there be a fair amount 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 503 

of space in the transverse diameter. The same limits may be laid down 
with regard to tumors or other sources of obstruction. 

Other Causes Justifying Craniotomy. — There are a few other conditions 
in which craniotomy is justifiable, independently of pelvic contraction, 
such as certain conditions of the soft parts which are supposed to render 
the passage of the head peculiarly dangerous to the mother. Among 
them may be mentioned swelling and inflammation of the vagina from 
the length of the previous labor, bands and cicatrices of the vagina, and 
occlusion and rigidity of the os. It is hardly too much to say that with 
a proper use of the resources of midwifery the destruction of a living 
foetus for any of these conditions might be obviated. The most common 
of them is undoubtedly swelling of the soft parts causing impaction of 
the head — an occurrence which ought to be invariably prevented by a 
timely use of the forceps. Should interference unfortunately be delayed 
until impaction has actually taken place, doubtless no other resource but 
craniotomy would be left ; but such cases, it is to be hoped, are now of 
rare occurrence in British practice. Undue rigidity of the os can be 
overcome by dilatation with the caoutchouc bags, or, in more serious 
cases, by incision, which would certainly be less perilous to the mother 
than dragging even a mutilated foetus through the small and rigid aper- 
ture. In the case of bands and cicatrices in the vagina, dilatation or 
incision will generally suffice to remove the obstruction ; but even were 
this not so, here, as in excessive rigidity of the perineum, it would be 
better that slight lacerations should take place than that the child should 
be killed. 

Certain Complications of Labor are held to Justify Craniotomy. — Cer- 
tain complications of labor are held to justify craniotomy, such as rup- 
ture of the uterus, convulsions, and hemorrhage. The application of 
the forceps or turning will generally answer our purpose equally well, 
especially as we have the means of dilating the os sufficiently to admit 
of one or other of them being performed when the natural dilatation is 
not sufficient. Craniotomy in rupture of the uterus will also be rarely 
indicated, as we have seen that gastrotomy appears to afford a better 
chance to the mother in those cases in which the fetus lias partially or 
entirely escaped from the uterine cavity. 

Excessive Size of the Foetus may r<'<jn/rc the Operation. — Want of pro- 
portion between the fetus and the pelvis, depending on undue size of 
the head, either natural or the result of disease, may render the operation 
essential. In the former of these eases we shall generally have first 
attempted delivery with the forceps, and if it has failed there can be no 
doubt as to the propriety of lessening the bulk of the head by perforation. 

Craniotomy when the Child is believed t<> he Dead. — In most obstetric 
works we are recommended to perforate rather than apply the forceps 
when we are convinced that the child has ceased to live. This advice IS 
based on the greater facility with which craniotomy can be performed 
and its supposed greater safety to the mother. There '•an he no doubt 
of the ease with which the child can be extracted after perforation when 
the pelvis i- not contracted; and, if we could always !><• sure <»!' our 
diagnosis, the rule might be a good one. Before acting on it. however, 
we must bear in mind the extreme difficulty of positively ascertaining 



504 OBSTETRIC OPERATIONS. 

the death of the foetus. Of the signs usually relied on for this purpose 
there are scarcely any which are not open to fallacy except peeling of the 
scalp and disintegration of the cranial bones, which do not take place 
unless the child has been dead for a length of time, and are therefore 
useless in most instances. Discharge of the meconium constantly takes 
place when the child is alive ; a cold and pulseless prolapsed cord may 
belong to a twin ; and the foetal heart may become temporarily inaudible 
although the child is not dead. If, indeed, we have carefully watched 
the foetal heart all through the labor, and heard it become more and 
more feetde, and finally stop altogether, we might be certain that the 
child has died ; but surely such observations would rather indicate an 
early recourse to the forceps or version, so as to obviate the fatal result 
we know to be impending. 

Perforation of the After-coming Head. — In certain breech presenta- 
tions or after turning it may be found impossible to extract the head 
without diminishing its size by perforating behind the ear. In such 
cases we know to a certainty whether the child be alive or dead before 
resorting to the operation. 

Perforation is an Essential Preliminary both in Craniotomy arid 
Cephalotripsy. — The first step, whether we resort to cephalotripsy or 
craniotomy, is perforation, which will therefore be first described. In 
the former the desirability of first perforating the head is not always 
recognized. To endeavor to crush the head without perforating is need- 
lessly to increase the difficulties of the case, and it should be remembered, 
as a cardinal rule, that perforation is an essential preliminary to the 
proper use of the cephalotribe. 

Method of Perforation. — Before perforating we must carefully ascer- 
tain the exact relation of the os to the presenting part, since in many 
cases the operation is performed before the os is fully dilated, when there 
is a risk of wounding the cervix. Two or more fingers of the left hand 
should be passed up to the head and placed against the most prominent 
part of the parietal bone. Under these, used as guard (Fig. 185), the 
perforator should be cautiously introduced until the scalp is reached. 
It is important to fix on a bony part of the skull, and not on a suture 
or fontanelle, for puncture, because our object is to break up the vault 
of the cranium as much as possible, so as to allow the skull to collapse. 
When the instrument has reached the point we have selected, it should 
be made to penetrate the scalp and skull with a semi-rotatory boring 
motion, and advanced until it has sunk up to the rests, which will 
oppose its further progress. Occasionally considerable force will be 
necessary to effect penetration, more especially if the scalp be swollen by 
long-continued pressure ; and this stage of the operation will be facili- 
tated by causing an assistant to steady the head by pressure on the foetus 
through the abdomen, more especially if it be still free above the pelvic 
brim. We must then press together the handles of the instrument, 
which will have the effect of widely separating the cutting portion and 
making an incision through the bones. After this the point should 
be turned round, and again opened at right angles to the former incision, 
so as to make a free crucial opening. During this process care must be 
taken to bury the perforator in the skull up to the rests, so as to avoid 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 



•305 



the possibility of injuring the maternal soft parts. The instrument 
should now be introduced within the skull and moved freely about, so 
as to thoroughly and completely break up the brain. Especial care must 
be taken to reach the medulla oblongata and base of the brain, for if 
these were not destroyed we might subject ourselves to the distress of 
extracting a child in whom life was 
not extinct. If this part of the opera- 
tion be thoroughly performed, there 
will be no necessity for washing out 
the brain by the injection of warm 
water, as is sometimes recommended, 
for the broken-up tissue will escape 
freely through the opening made by 
the perforator. 

Perforation of the After-coming 
Head. — The perforation of the after- 
coming head does not generallv offer 
any particular difficulty. It is ac- 
complished in the same manner, the 
child's body being well drawn out of 
the way by an assistant. The point 
of the perforator, carefully guarded 
by the finger, is guided up to the 
occiput or behind the ear, where it is 
inserted. 

It is sometimes Useful to Postpone 
Extraction. — If there be no necessity 
for very rapid delivery, and the pains 
be still present, it is often advisable to 
wait ten minutes or a quarter of an 
hour before proceeding to extract. 
This delay will allow the skull to 
collapse and become moulded to the 
cavity of the pelvis when forced down 
by the pains, and possibly the natural effort may suffice to finish the 
labor in that time; or at least the head will have descended farther, 
and will be in a better position for extraction. Should perforation be 
required after having failed to deliver with the forceps — and this is only 
likely to be the case when the obstruction is comparatively slight — it is 
certainly a good plan to perforate without removing the forceps, which 
may then be used as tractors. 

VVe have now to decide on the method of extraction ; and our choice 
generally lies between the cephalotribe and the craniotomy forceps, 
although in some few cases, in which the pelvic contraction i< slight, 
version may be advantageously employed. 

Oomparative Merits of Omphalotripsy and Craniotomy. — Those who 
have used both must, I think, admit that in any ordinary case, in which 
the obstruction is not great and only a comparatively slight diminution 
in the size of the head is required, cephalotripsy is infinitely the easier 
operation. The facility with which the skull can be crushed is some- 




Perforation of the Skull. 



506 OBSTETRIC OPERATIONS. 

times remarkable, and those who will take the trouble to read the reports 
of the operation published by Braxton Hicks, Kidd, and others cannot 
fail to be struck with the rapidity with which the broken-down head 
may often be extracted. This is far from being the case with the crani- 
otomy forceps, even when the obstruction is moderate only ; for it may 
be necessary to use considerable traction, or the blades may take a proper 
grasp with difficulty, or it may be essential to break down and remove 
a considerable portion of the vault of the cranium before the head is 
lessened sufficiently to pass. Daring the latter process, however care- 
fully performed, there is a certain risk of injuring the maternal struc- 
tures, and in the hands of a nervous or inexperienced operator this 
danger, which is entirely avoided in cephalotripsy, is far from slight. 
The passage of the blades of the cephalotribe is by no means difficult, 
and I think it must be admitted that the possible risks attending it are 
comparatively small. On account, therefore, of its simplicity and safety 
to the maternal structures, I believe cephalotripsy to be decidedly the 
preferable operation in all cases of moderate obstruction. 

When we approach the lower limit, and have to do with a very marked 
amount of pelvic deformity, the two operations stand on a more equal 
footing. Then the deformity may be so great as to render it difficult 
to pass the blades of even the smallest cephalotribe sufficiently deep 
to grasp the head firmly, and even when they are passed the space is 
often so limited as to impede the easy working of the instrument. 
Besides this, repeated crushings may be required to diminish the skull 
sufficiently. I attach but little importance to the argument that the 
diminution of the skull in one diameter increases its bulk in another. 
The necessity of removing and replacing the blades on another part of 
the skull, and of repeating this perhaps several times in the manner 
recommended by Pajot, is a far more serious objection. To do this in 
a contracted pelvis involves, of necessity, the risk of much contusion. 
Fortunately, cases of this kind are of extreme rarity — much more so 
than is generally believed — but when they do occur they tax the resources 
of the practitioner to the utmost. 

On the whole, the conclusion I would be inclined to arrive at with 
regard to the two operations is, that in all ordinary cases cephalotripsy 
is safer and easier, whereas in cases with considerable pelvic deformity 
the advantages of cephalotripsy are not so well marked, and craniotomy 
may even prove to be preferable. 

Description of the Operation. — The first step in using the cephalotribe 
is the passage of the blades. These are to be inserted in precisely the 
same manner and with the same precautions as in the high forceps 
operation. In many cases the os is not fully dilated, and it is absolutely 
essential to pass the instrument within it. Special care should therefore 
be taken to avoid any injury to its edges, and for this purpose two or 
three fingers of the left hand, or even the whole hand, should be passed 
high up, so as thoroughly to protect the maternal structures. In order 
that the base of the skull may be reached and effectually crushed, the 
blades must be deeply inserted ; and in doing this great care and gentle- 
ness must be used. As the projecting promontory of the sacrum 
generally tilts the head forward, the handles of the instrument, after 



OPERATIONS IXVOLVIXG DESTRUOTIOX OF FOETUS. 



50" 



locking, must be well pressed backward toward the perineum. If the 
blades do not lock easily, or if any obstruction to their passage be ex- 
perienced, one of them must be withdrawn and reintroduced, just as in 
forceps operations. Care must be taken, as the instrument is being in- 
serted, to fix and steady the head by abdominal pressure, since it is 
generally far above the brim, and would readily recede if this precau- 
tion were neglected. When the blades are in situ we proceed to crush 
by turning the screw slowly, and as the blades are approximated the 
bones yield and the cephalotribe sinks into the cranium. The crushed 
portion then measures, of course, no more than the thickness of the 
blades — that is, about 1J inches. This is necessarily accompanied by 
some bulging of the part of the cranium that is not within the grasp of 
the instrument (Fig. 186), but in slight de- 
formity this is of no consequence, and we may 
proceed to extraction, waiting, if possible, for 
a pain, and drawing at first downward in the 
axis of the pelvic inlet, as in forceps delivery, 
then in the axis of the outlet. The site of 
perforation should be examined to see that no 
spiculae of bone are projecting from it, and if 
so they should be carefully removed. In 
such cases the head often descends at once and 
with the greatest ease. Should it not do so, 
or should the obstruction be considerable, a 
quarter turn should be given to the handles 
of the instrument, so as to bring the crushed 
portion into the narrower diameter and the 
uncrushed portion into the wider transverse 
diameter. It may now be advisable to re- 
move the blades carefully, and to reintroduce 
them with the same precautions, so as to crush 
the unbroken portion of the skull. This adds 
materially to the difficulties of the case, since 
the blades have a tendency to fall into the 
deep channel already made in the cranium, 
and so it is by no means" always easy to seize 
the skull in a new direction. Before reapply- 
ing them, if the condition of the patient be 
good and pains be present, it may be well to 
wail an hour or more, in the hope of the head 
being moulded and pushed down into the 
pelvic cavity. This Mas the plan adopted by 
Dubois, and, according to Tarnier, was the secret of his great success in 
the operation. Pajot's method of repeated crushings in the greater 
degrees of contraction is based on the same idea, and he recommends 
that the instrument should be introduced at intervals of t\\<>. three, 
or four hours, according to the state of the patient, until the head is 
thoroughly crushed, no attempts at traction being used, and expulsion 
being left to the natural powers. This, he says, should always !>«• done 
when the contraction i> below '1\ inches, and he maintains that it is 




Foetal Head crushed by the 
< lephalotribe. 



508 



OBSTETRIC OPERATIONS. 



Fig. 187. 



quite possible to effect delivery by this means when there is only 1|- 
inches in the antero-posterior diameter. The repeated introduction of 
the blades in this fashion must necessarily be hazardous, except in the 
hands of a very skilful operator ; and I believe that if a second applica- 
tion fail to overcome the difficulty, which will only be very exception- 
ally the case, it would be better to resort to the measures presently to be 
described. 

Destruction of the Base of the Skull from Within by the Basilyst. — 
professor Simpson of Edinburgh 1 has recently suggested the use of an 
instrument which he calls a " basilyst." Its object is to 
break up the base of the foetal skull from within, after 
the method originally proposed by Guy on. The screw- 
like portion of the instrument (Fig. 187), which is in- 
serted through the perforation made in the cranial vault, 
is driven through the hard base, which is then disin- 
tegrated by the separate movable blade. If experience 
proves that this instrument can be readily worked, it 
promises to be a valuable addition to our armament- 
arium, since it will effectually destroy the most resistant 
portion of the skull without risk of injury to the maternal 
structures, and thus very materially facilitate extraction. 
Extraction by the Craniotomy Forceps. — Should we 
elect to trust to the craniotomy forceps for extraction, 
one blade is to be introduced through the perforation, 
and the other, in apposition to it, on the outside of the 
scalp. In moderate deformities traction applied during 
the pains may of itself suffice to bring down the head. 
Should the obstruction be too great to admit of this, it 
is necessary to break down and remove the vault of the 
cranium. For this purpose Simpson's cranioclast answers 
better than any other instrument. One of the blades is passed within 
the cranium, the other, if possible, between the scalp and the skull, and 
the portion of bone grasped between them is broken off; this can gen- 
erally be accomplished by a twisting motion of the wrist, without using 
much force. The separated portion of bone is then extracted, the greatest 
care being taken to guard the maternal structures during its removal by 
the fingers of the left hand. The instrument is then applied to a fresh 
part of the skull, and the same .process repeated, until as much of the 
vault of the cranium as may be necessary is broken up and removed. 
Advantages of bringing down the Face in Difficult Cases. — Dr. Braxton 
Hicks 2 has conclusively shown that in difficult cases, after the removal 
of the cranial vault, the proper procedure is to bring down the face, 
since the smallest measurement of the skull after the removal of the 
upper part of the cranium is from the orbital ridge to the alveolar edge 
of the superior maxillary bone. This alteration in the presentation he 
proposes to effect by a small blunt hook, made for the purpose, which is 
forced into the orbit, by means of which the face is made to descend. 
Barnes recommends that this should be done by fixing the craniotomy 
forceps over the forehead and face and making traction in a backward 

1 Edith. Med. Journ., April, 18S0. 2 Obst. Trans., vol. vii. 



Professor Simpson's 
Basilyst. 



OPERATIONS INVOLVING DESTRUCTION OF FCETUS. 509 



Fig. 183. 



Fig. 189. 



direction, so as to get the face past the projecting promontory of the 
sacrum. The importance of bringing down the face was long ago pointed 
out by Burns, but it had been lost sight of until Hicks again drew 
attention to it in the paper referred to. In the class of cases in which 
this procedure is yaluable the risk to the maternal passages from the 
removal of the fractured portions of bone must always be consider- 
able, and it is of great importance not only to preserve the scalp as 
entire as possible, so as to protect them, but to use the utmost possible 
care in removing the broken pieces of bone. 

Extraction of the Body. — When the extraction of the head has been 
effected, either by the cephalotribe or the craniotomy forceps, there is 
seldom much difficulty with the body. By traction on the head one of 
the axilla? can easily be brought within reach, and if the body do not 
readily pass the blunt hook should be introduced and traction made until 
the shoulder is delivered. The same can then be done with the other 
arm. If there be still difficulty, the cephalotribe may be used to crush 
the thorax. The body is, however, so compressible that this is rarely 
required. 

[The craniotomy forceps chiefly in use with us were devised by the 
late Prof. Charles D. Meigs for his second operation upon Mrs. Bey hold 
of Philadelphia in 1833, and have been used 
repeatedly since, either as tractors or for redu- 
cing the size of the foetal head, in cases of de- 
formity of the pelvis. 1 Some obstetricians prefer 
the less curved and broader-bladed instrument 
of Great Britain as a tractor ; but for the general 
purposes of picking away the cranial bones and 
drawing down the base of the skull in cases of 
extreme pelvic deformity there is no more simple 
appliance than that of Dr. Meigs. 

To act upon an oval body like the foetal head 
Dr. M. was obliged to prepare two forms of for- 
ceps — straight and curved — to be used as might 
be required according to the part of the skull to 
be broken down or drawn upon. These are 
lightly made, serrated, and 12^- inches in length. 
-—Ed.] 

Embryotomy in Transverse Presentations in 
which Turning is Impossible. — There only re- 
mains for US to Consider the second class of 

destructive operations. These may be necessary 

in long-neglected cases of arm presentation in 

which turning is found to be impracticable. 

Here, fortunately, the question of killing the foetus does nol aria 

it will, almost necessarily, have already j 

pressure. We have two operation- in 

evisceration. 




Curvi 

Craniotomy 
Forceps. 



moe 
►erished from the continuous 
-elect Prom — decapitation and 



[ l The illustrations i?i von are taken from the instruments devised by Dr. Meigs as an 
improvement upon his original pattern, and will he Been to differ from those usually 

presented in American obstetrical publications. — Ed.] 



510 OBSTETRIC OPERATIONS. 

Decapitation. — The former of these is an operation of great antiquity, 
having been fully described by Celsus. It consists in severing the neck, 
so as to separate the head from the body ; the body is then withdrawn 
by means of the protruded arm, leaving the head in utero to be subse- 
quently dealt with. If the neck can be reached without great difficulty 
— and in the majority of cases the shoulder is sufficiently pressed down 
into the pelvis to render this quite possible- — there can be no doubt that 
it is much the simpler and safer operation. 

Methods of Dividing the Neck. — The whole question rests on the pos- 
sibility of dividing the neck. For this purpose many instruments have 
been invented. The one generally recommended in this country is 
known as Ramsbotham's hook, and consists of a sharply-curved hook 
with an internal cutting edge. This is guided over the neck, which is 
divided by a sawing motion. There is often considerable difficulty in 
placing the instrument over the neck, although, if this were done, it 
would doubtless answer well. Others have invented instruments, based 
on the principle of the apparatus for plugging the nostrils, by means of 
which a spring is passed round the neck, and to the extremity of the 
spring a short cord or the chain of an ecraseur is attached ; the spring 
is then withdrawn and brings the chain or cord into position. The 
objection to any of these apparatuses is that they are unlikely to be at 
hand when required, for few practitioners provide themselves with costly 
instruments which they may never require. It is of importance, there- 
fore, that we should have at our command some means of dividing the 
neck which is available in the absence of any of these contrivances. 
Dubois recommends for this purpose a strong pair of blunt scissors. 
The neck is brought as low as possible by traction on the prolapsed arm, 
and the blades of the scissors guided carefully up to it. By a series of 
cautious snipping movements it is then completely divided from below 
upward. This, if the neck be readily within reach, can generally be 
effected without any particular difficulty. Dr. Kidd of Dublin, 1 who 
strongly advocates this operation, recommends that an ordinary male 
elastic catheter, strongly curved and mounted on a firm stilette, or, still 
better, on a uterine sound, should be passed round the neck. Previous 
to introduction a cord should be attached to the extremity of the cath- 
eter, which is left round the neck when it is withdrawn. By means of 
this cord a strong piece of whipcord or the wire of an ecraseur can easily 
be drawn round the neck and used for dividing it. The former, to pro- 
tect the maternal structures, may be worked through a speculum, and 
by a series of lateral movements the neck is easily severed. The Ecra- 
seur, however, offers special advantage, since it entirely does away with 
any risk of injuring the mother. 

Withdrawal of the Body and Delivery of the Head. — After the neck 
is divided the remainder of the operation is easy. The body is with- 
drawn without difficulty by the arm, and we then proceed to deliver 
the head. By abdominal pressure this, in most cases, can be pushed 
down into the pelvis, so as to come easily within reach of the cephalo- 
tribe, which is by far the best instrument for extraction. Preliminary 
perforation is not necessary, since the brain can escape through the sev- 

1 Dublin Quart. Journ., May, 1871. 



CJESAREAN SECTION. 511 

ered vertebral canal. The secret of doing this easily is to fix and press 
down the head sufficiently from above, otherwise it would slip away 
from the grasp of the instrument. The perforator and craniotomy for- 
ceps may be used if the cephalotribe be not at hand. Perforation is, 
however, by no means always easy, on account of the mobility of the 
head. After it is accomplished one blade of the craniotomy forceps is 
passed within the skull, the other externally, and the head slowly drawn 
down. 

Evisceration. — The alternative operation of evisceration is a much 
more troublesome and tedious procedure, and should only be used when 
the neck is inaccessible. The first step is to perforate the thorax at its 
most depending part, and to make as wide an opening into it as possible 
in order to gain access to its contents. Through this the thoracic viscera 
are removed piecemeal, being first broken up as much as possible by the 
perforator, and then, the diaphragm being penetrated, those in the abdo- 
men. The object is to allow the body to collapse and the pelvic extrem- 
ities to descend, as in spontaneous evolution. This can be much facili- 
tated by dividing the spinal column with a strong pair of scissors intro- 
duced into the opening made in the thorax, so that the body may be 
doubled up as on a hinge. Here the crotchet may find a useful appli- 
cation, for it can be passed through the abdominal cavity and fixed on 
some point in the interior of the child's pelvis, and thus strong traction 
can be made without any risk of injury to the mother. It can be readily 
understood that this process is so lengthy and difficult as to render it 
probably the most trying of obstetric operations; it is certainly inferior 
in every respect to decapitation, and is only to be resorted to when that 
is impracticable. 

[The Csesarean operation has been performed in the United States in 
11 cases of impaction of the foetus in a transverse position, because of 
the great difficulty of accomplishing either decapitation or evisceration, 
with a saving of 7 women. The 4 deaths were from exhaustion. — Ed.'] 



CHAPTER VI. 

THE CESAREAN SECTION; I'oKKo'S OPERATION; SYMPHYSEOTOMY. 

History of the Coesarean Section. — The Cesarean section lias perhaps 
given rise to more discussion than any other subject connected with mid- 
wifery, and there is yet much difference of opinion as to the limits of, 
and indications for, the operation, The period at which the Caesarean 
section was first resorted to is not known with accuracy. It seems t<- 
have been practised by the Greeks after the death of the mother, and 
Pliny mentions thai Scipio Africanufl and Manlius were born in tlii- 
way. The name of Caesar Is said to have been given to children so 
extracted, and afterward to have been assumed as a family patronymic, 



512 OBSTETRIC OPERATIONS. 

These children were dedicated to Apollo ; whence arose the practice of 
things sacred to that god being taken under the special protection of the 
family of the Csesars. Many celebrities have been supposed to owe their 
lives to the operation ; among the rest, .iEsculapius, Julius Caesar, and 
our own Edward VI. Regarding the two latter, there is conclusive proof 
that the tradition is without foundation. There is no doubt that the ope- 
ration was constantly practised on women who had died at an advanced 
period of pregnancy, and indeed it has at various times been enforced 
by law. Thus, among the Romans it was decreed by Numa that no 
pregnant woman should be buried until the fetus had been removed by 
abdominal section. The Italian laws also made it necessary, and the 
operation has always received the strong support of the Roman Church. 
So lately as the middle of the eighteenth century the king of Sicily sen- 
tenced to death a physician who had neglected to practise it. The first 
authentic case in which the operation was performed on a living woman 
occurred in 1491. It was afterward practised by Nufer in 1500; and 
in 1581, Rousset published a work on the subject in which a number 
of successful cases were related. In English works of that time it is 
not alluded to, although it was undoubtedly performed on the Continent, 
and to such an extent that its abuse became almost proverbial. We have 
evidence in Shakespeare, however, that the operation was familiarly 
known in this country, since he tells us that 

" Macduff was from his mother's womb 
Untimely ripped." [ x ] 

Pare and Guillemeau, amongst the writers of the period, were noted for 
their hostility to the operation, while others equally strongly upheld it. 

In this country it has scarcely ever been performed in a manner which 
offers even the faintest hope of success. It has been looked upon as 
almost necessarily fatal to the mother, and it has therefore been delayed 
until the patient has arrived at the utmost stage of exhaustion. For 
example, in looking over the records of British cases it is no uncommon 
thing to find that the Cesarean section was resorted to two, three, or 
even six days after labor had begun, and when the patient was almost 
moribund. With rare exceptions within the last few years the opera- 
tion has been performed in what may be called a haphazard way. In 
many cases long and fruitless attempts at delivery by craniotomy had 
already been made, so that the passages had been subjected to much con- 
tusion and violence. Little or no attempt has been made to obviate the 
well-known risks of abdominal operations ; no care has been taken to 
prevent blood and other fluids finding their way into the peritoneal cav- 
ity, and no means have been adopted subsequently to remove them. It 
is therefore not so much a matter of surprise that the mortality has been 
so great, but rather that any cases have recovered. 

From what we know of the history of ovariotomy, its early fatality, 
and the extreme and even apparently exaggerated precautions which are 
essential to its success, it is fair to conclude that if the Cesarean section 

\} To my mind, this refers to what had often taken place in ancient wars, where 
women were ripped open by soldiers with a sword. The expression untimely does not 
indicate that the foetus had come to maturity or that the woman was in labor. — Ed.] 



C&SABEAy SECTIOX. 513 

were performed, as it is to be hoped it always will be in future, with the 
same careful attention to minute details as ovariotomy, the results would 
not be so disastrous. Making every allowance for these facts, it must 
be admitted that the Cesarean section is necessarily almost a forlorn 
hope ; and in making these observations I have no intention of contest- 
ing the well-established rule of British practice, that it is not admissible 
as an operation of election, and must only be resorted to when delivery 
per vias naturales is impossible. 

Statistical Returns not Reliable. — The mortality, as given in statistical 
returns from various sources, differs so greatly as to make them but lit- 
tle reliable. Radford has tabulated the operations performed in this 
country up to 1868, and the list has been completed by Harris 1 up to 
1879. [ 2 ] The cases amount to 118 in all, of which 22 were successful, 
or rather more than 18 per cent. Michaelis and Kayser found that out 
of 258 and 338 operations, 54 and 64 per cent, respectively were fatal. 
These include operations performed under all sorts of conditions, even 
when the patient was almost moribund ; and until we are in possession 
of a sufficient number of cases performed under conditions showing that 
the result is obviously due to the operation, in which it was undertaken 
at an early period of labor and performed with a reasonable amount of 
care, it is obviously impossible to arrive at any reliable conclusions as to 
the mortality of the operation. That it is necessarily hopeless is cer- 
tainly not the case, and we know that on the Continent, where it is 
resorted to much oftener and earlier in labor than in this country, there 
are authentic cases in which it has been performed twice, thrice, and 
even, in one instance, four times, on the same patient. Kayser thinks 
that a second operation on the same patient affords a better prognosis 
than a first, probably because peritoneal adhesions resulting from the 
first operation have shut off the general abdominal cavity from the 
uterine wound ; and he believes that in second operations the mortality 
is not more than 29 per cent. 

The Ccesarean Section in America. — The Csesarean section has been 
much more successful in America than in Great Britain. Dr. Harris 
of Philadelphia, who has paid much attention to the subject, has col- 
lected 134 cases occurring in the United States, of which 53 were suc- 
cessful as regards the mother. These favorable results he refers partly 
to the fact that none of the American cases were the subjects of mollities 
ossium, rachitic patients forming one-half of the entire Dumber, and partly 
to the prevalence of habits of beer- and gin-drinking in this country. 
He also gives some interesting facts showing how remarkably the mor- 
tality of the operation is lessened when it is performed ><><>n and the 
patient is not exhausted by long and fruitless labor. Out of 28 selected 
eases of this kind, 21, or 75 per cent., were successful. [23 children 
were delivered alive, and 19 saved. — Ki>.] 

[Latest Cesarean Statistics of America. — For some years we have 

^'The Csesarean Operation in the United Kingdom," Brit. .!/<'/. /own., April •'*, 
1880. 

['-' The late Dr. Radford in 1S80 tahulated the Uriti>h «.| erations t" May, 1879, and 
presented 132 cases, failing to notice 4, 1 of which recovered. To these I add 2 of a 
later date, both of which were saved, making in nil 138 cases, w 'ih 26 I -Ei>.] 

33 



514 OBSTETRIC OPERATIONS. 

been very decidedly retrograding in our proportion of cures to deaths 
and of timely to late operations, and have been gradually increasing the 
percentage of deaths in the whole record. Ten years ago, when we had 
had 101 operations, we counted 45 women saved, or a fraction below 45 
per cent. In the ten years we have added 33 cases, with 25 women and 
19 children lost, thereby reducing the number of cures below 40 per 
cent, Worse still than this, the operations of the past ten months in 
the United States (April 1, 1884, to Feb., 1885), number 6, and all of 
the women and children were lost. But 2 of these last operations have 
yet been reported in journals, but all are promised for publication. Of 
the 33 operations referred to, 24 were performed upon cases regarded as 
in an uniavorable condition, and only 8 were operated upon within the 
first twenty-four hours of labor. It is not, then, to be wondered at that 
75 per cent, of the women perished. It is folly in an accoucheur to expect 
a surgeon to save his patient when broken down and exhausted by the 
length of her labor. 

We have had 134 Cesarean operations in the United States, and the 
addition made by Mexico and the West Indies increases the number by 
9. Of the 134, there were saved 53 women, and 7 of the 9, making, 
in all, 143 operations, with 60 women saved. Of the 134 cases in the 
United States, 26 were dwarfs, ranging in height from 3 feet to 4 feet 8 
inches, one-half being from 3 to 4 feet ; and of these 26 but 7 were 
saved. The shortest women to recover were respectively 3 feet 9 inches, 
3 feet 11-^ inches, and 4 feet. Dwarfs should not be allowed to continue 
in labor more than from two to four hours, as they rapidly become 
exhausted, and are apt to die of shock, exhaustion, or peritonitis. One 
dwarf, operated upon and saved after a labor of two hours, was already 
showing the evidences of exhaustion. By acting very promptly the 
labor only having lasted \\ hours, a physician of Brest, France, was 
successful in saving a woman only 35 inches in height, with her child, 
a few years ago. He appeared to know the value of time to such a 
patient, and, when called in, rapidly made his arrangements for using 
the knife. The term " early " is a relative one, and what might be such 
as a measure of time in one case would not be in another. " Timely " has 
no measure in hours, but relates more to the strength and condition of 
the patient. If the strength, pulse, and morale of the woman indi- 
cate a favorable condition, and she has not had active labor beyond 
a few hours, she will in the majority of instances in our country 
recover. — Ed.] 

Results to the Child. — The mortality of the children likewise cannot 
be ascertained from statistical returns, since in the large majority of 
cases in which dead children were extracted the result had nothing to do 
with the operation. Indeed, there is nothing in the operation itself 
which can reasonably be supposed to affect the child. If, therefore, the 
child be alive when the operation is commenced, there is every probabil- 
ity of its being extracted alive ; and Radford's conclusion, that " the 
risk to infants in Cesarean births is not much greater than that which 
is contingent on natural labor, provided correct principles of practice are 
adopted," probably very nearly represents the truth. 

Causes Requiring the Operation. — The Csesarean section is required 



CJESAEEAN SECTION. 515 

when there is such defective proportion between the child and the 
maternal passages that even a mutilated foetus cannot be extracted. 
This in by far the greatest number of cases is due to deformity of the 
pelvis arising from rickets or mollities ossium. The latter may occur 
in a patient who has been previously healthy and who has given birth 
to living children. It is a more common cause of the extreme varieties 
of deformity than rickets, and out of 77 British cases, tabulated by Rad- 
ford, in 43 the deformity was produced by osteo-malacia and in 14 only 
by rickets.[ L ] In certain cases the pelvis, itself may be of normal size, 
but has its cavity obstructed by a solid tumor of the ovary, of the uterus 
itself, or one growing from the pelvic wall. The obstruction may also 
depend on morbid conditions of the maternal soft parts, of which the 
most common is advanced malignant disease of the cervix. Other con- 
ditions may, however, render the operation essential. Thus, Dr. New- 
man 2 records a case in which he performed it for insurmountable resist- 
ance and obstruction of the cervix, which was believed at the time to be 
caused by malignant disease. The patient recovered, and was subse- 
quently delivered naturally and without anything abnormal being made 
out. This renders it probable that the disease was not malignant, and 
it may possibly have been an extensive inflammatory exudation into the 
tissues of the cervix, subsequently absorbed. I myself was present at a 
Cesarean section performed in Calcutta in the year 1857 when the pel- 
vis was so uniformly blocked up with exudation, probably due to exten- 
sive pelvic cellulitis or hematocele, that the operation was essential. 

Limits of Obstruction Justifying the Operation. — Different accoucheurs 
have fixed on various limits for the operation. Most British authorities 
are of opinion that it need not be resorted to if the smallest diameter of 
the pelvis exceed 1^- inches. 3 This question has already been considered 
in discussing craniotomy, and it has been shown that a mutilated foetus 
may be drawn through a pelvis of 1| inches anteroposterior diameter, 
provided there be a space of 3 inches in the transverse diameter. It' 
sufficient space for using the necessary instruments do not exist, the 
(Cesarean section may be required even when there is a larger antero- 
posterior diameter than 1\ inches. This i< especially likely to occur 
when we have to do with deformity arising from mollities ossium, in 
which the obstruction is in the sides and outlet of the pelvis, the true 
conjugate being sometimes even elongated. On the Continent tin' 
Caesarean section is constantly practised, as an operation of election, 
when the smallest diameter measures from 2 to '1\ inches ; and when 
the child is known to be alive some foreign authors recommend ii when 
there is as much as 3 inches in the antero-posterior diameter. In this 
country, where the life of the child is most properly considered of sec- 
ondary importance to the safety of the mother, we cannot fix one limit 
for the operation when the child is living and another when it is dead. 
Nor, I think, can we admit the desire of the mother to run the risk, 

[' I must again fill up the record of Dr. Radford, or his 132 cases, ■><> were the subjects 
of mollities ossium, and in 31 the deformity of the pelvis was attributed i'» rickets : 1 I 
cases were the subjects of cancer and la of tumors. — Ed. ] 

2 Obst. Trans., vol. vii. p. 343. 

3 In Dr. Parry's table of 70 craniotomies there are :;i cases of 2 t<> -' inches conju- 
gate. 



516 OBSTETRIC OPERATIONS. 

rather than sacrifice the child, as a justification of the operation, although 
this is laid down as an indication by Schroeder. 1 Great as are the dan- 
gers attending craniotomy in extreme deformity, there can be no doubt 
that we must perform it whenever it is practicable, and only resort to 
the Cesarean section when no other means of delivery are possible. 

For this reason I think it unnecessary to discuss the question whether 
we are justified in destroying the foetus in several successive pregnancies 
when the mother knows that it is impossible for her to give birth to a 
living child. Denman was the first to question the advisability of 
repeating craniotomy on the same patient. Amongst modern authors, 
Radford takes the most decided view on this point, and distinctly 
teaches that even when delivery by craniotomy is possible, it " can be 
justified on no principle, and is only sanctioned by the dogma of the 
schools or by usage," and that, therefore, the Cesarean section should 
be performed with the view of saving the child. Doubtless, much can 
be said from this point of view, but, nevertheless, he would be a bold 
man who would deliberately elect to perform the Cesarean section on 
such grounds. 2 It is to be hoped, however, that in these days the 
induction of premature labor or abortion would always spare us the 
necessity of deciding so delicate a point. 

Post-mortem Gcesarean Operation. — The Cesarean section may also 
be required in cases in which death has occurred during pregnancy or 
labor. This was the indication for which it was first employed, and it 
has constantly been performed when a pregnant woman has died at an 
advanced period of utero-gestation. There is no doubt that a prompt 
extraction of the child under these circumstances has frequently been 
the means of saving its life, but by no means so often as is generally 
supposed. Thus, Schwartz 3 showed that out of 107 cases not one living 
child was extracted. Duer 4 has written an interesting paper on this 
subject in which he has tabulated 55 cases of post-mortem Caesarean 
sections. In 40 a living child was extracted, the time elapsing after the 
death of the mother being as follows : " Between 1 and 5 minutes, in- 
cluding ' immediately' and 'in a few minutes/ there were 21 cases; 
between 5 and 10 minutes, none; between 10 and 15 minutes, 13 cases; 
between 15 and 23 minutes, 2 cases ; after 1 hour, 2 cases ; and after 2 
hours, 2 cases." In those extracted, however, after the lapse of an hour 
the children did not ultimately survive, and the cases themselves seem 
open to some doubt. 

Want of Success in Post-mortem Operation. — The reason that the want 
of success has been so great is doubtless the delay that must necessarily 
occur before the operation is resorted to, for, independently of the fact 
that the practitioner is seldom at hand at the moment of death, the very 
time necessary to assure ourselves that life is actually extinct will gen- 

1 Manual of Midwifery, p. 202. 

2 This was done twice successfully by Prof. William Gibson in the case of Mrs. 
Keybold of Philadelphia in 1835 and 1837, after she had twice been delivered by 
'craniotomy under Prof. Charles D. Meigs, who declined destroying any more children 
for her. Mrs. E. still lives at the age of seventy-five, and the daughter likewise, with 
her four children. The son died at 43, leaving two children. — Harris. 

3 Monat.f. Geburt suppl. vol., 1861, p. 121. 

4 " Post-mortem Delivery," Am. Joum. of ObsL, Jan., 1879. 



CESAREAN SECTIOS. 517 

erally be sufficient to cause the death of the foetus. Considering the 
intimate relations between the mother and child, we can scarcely expect 
vitality to remain in the latter more than a quarter, or at the outside 
half an hour, after it has ceased in the former. The recorded instances 
in which a living child was extracted ten, twelve, and even forty hours 
after death were most probably cases in which the mother fell into a 
prolonged trance or swoon, during the continuance of which the child 
must have been removed. A few authentic cases, however, are known 
in which there can be no reasonable doubt that the operation was per- 
formed successfully several hours after the mother was actually dead. 

Since, then, there is a chance, however slight, of saving the child's 
life, we are bound to perform the operation, even when so much time 
has elapsed as to render the chances of success extremely small. It 
might be considered almost superfluous to insist on the necessity of 
assuring ourselves of the mother's death before commencing the neces- 
sary incisions ; but, unfortunately, numerous instances are known in 
which mistakes in diagnosis have been made, and in which the first 
steps of the operation have shown that the mother was still alive. The 
operation should therefore always be performed with the same care and 
caution as if the mother were living. If death have occurred during 
labor, some have advised version as a preferable alternative. This can 
only be resorted to with any hope of success if the passages be in a con- 
dition to admit of delivery with rapidity; otherwise the delay occasioned 
by dilatation, even when forcibly accomplished, and the drawing of the 
child through the pelvis, will be almost necessarily fatal. The only 
argument in favor of version is, that it is less painful to the friend- ; 
and, if they manifest a decided objection to the Cesarean section, there 
can be no reason why an attempt to save the child in this way should 
not be made. 

Causes of Death after Cossarean Section. — The causes of death after 
the Csesarean section may, speaking generally, be classed under four 
principal heads: hemorrhage, peritonitis and metritis, shock, septicaemia, 
and exhaustion from long delay. These are pretty much the same as 
those following ovariotomy, and the resemblance between the two opera- 
tions is so great that modern experience as to the best mode of perform- 
ing ovariotomy, as well as regards the after-treatment, may be taken as 
a guide in the management of cases of Csesarean section. 

Hemorrhage is Frequent, although Seldom Fatal. — Hemorrhage t<> an 
alarming extent is a frequent complication, though seldom the cause of 
death. Thus, out of 88 operations the particulars of which have been 
carefully noted, severe hemorrhage occurred in 1 t, 6 of which terminated 
successfully, and in 4 only could the fatal result be ascribed i<» the loss 
of blood. In 1 of these the source of the hemorrhage 18 not mentioned, 
in another it came from the wound in the abdominal wall, and in the 
other 2 from the uterine incision being made directly over the placenta. 
In neither of the two latter was the loss of blood immediately final, for 
it was checked by uterine contraction, and only recurred after many 
hours had elapsed. The divided uterine sinuses and tin- open mouths 
of the vessels at the placental site are the most common sources of hem- 
orrhage. 



518 OBSTETRIC OPERATIONS. 

Means of Avoiding the Risk. — Much may be done to diminish the 
risk of bleeding, but even with every precaution it must be a source of 
danger. Hemorrhage from the abdominal wall may be best prevented 
by making the incision as nearly as possible in the line of the linea alba, 
so as not to wound the epigastric arteries, and by controlling bleeding 
by pressure-forceps as we proceed, as is done in ovariotomy. The prin- 
cipal loss of blood will be met with in dividing the uterus ; and this 
will be the greatest when the incision is near or over the placental site, 
where the largest vessels are met with. We are recommended to ascer- 
tain the position of the placenta by auscultation, and thus, if possible, to 
avoid opening the uterus near its insertion. But even if we admit the 
placental souffle to be a guide to its situation if the placenta be attached 
to the anterior walls of the uterus, a knowledge of its position would not 
always enable us to avoid opening the uterus in its immediate vicinity. 
We must, in the event of its lying under the incision, rather hope to 
control the hemorrhage by removing it at once from its attachments and 
rapidly emptying the uterus. When the child has been removed there 
may be a large escape of blood, but this will generally be stopped by 
the contraction of the uterus in the same manner as after natural labor. 
Should contraction not take place, the uterus may be firmly grasped for 
the purpose of exciting it. This plan is advocated by Winekel, who 
had a large experience in the operation, and by using free compression 
in this w T ay, and making a point of not closing the wound until the 
uterus is firmly contracted, he has never met with any inconvenience 
from hemorrhage. If bleeding continue, styptic applications may be 
used, as in a case reported by Hicks, Avho was obliged to swab out the 
uterine cavity with a solution of perchloride of iron. 

Peritonitis and Metritis are Frequent Causes of Death. — Among tl\e 
most frequent causes of death are peritonitis and metritis. Kayser 
attributes the fatal result to them in 77 out of 123 unsuccessful cases. 
The mere division of the peritoneum will not account for the frequency 
of this complication, since its occurrence is considerably more frequent 
than after ovariotomy, in which the injury to the peritoneum is quite as 
great ; and indeed greater, if we take into account the adhesions which 
have to be divided or torn in that operation. 

Degeneration of the Uterine Fibres supposed to be Unfavorable to 
Repair. — The division of the uterus must be regarded as one source 
of this danger. Dr. West lays great stress on its unfavorable condition 
after delivery for reparative action. He believes that the process of 
involution or fatty degeneration which commences in the muscular fibres 
previous to delivery renders them peculiarly unfitted to cicatrize; and 
he points out that on post-mortem examination the edges of the incision 
have been found dry, of unhealthy color, gaping, and showing no tend- 
ency to heal. On this account, Hicks and others have operated ten 
days or more before the full period of labor, in the hope that the risk 
from this source might be avoided. It is by no means certain, however, 
that the change in the uterine fibres is the cause of the wound not heal- 
ing, and involution will commence at once when the uterus is emptied 
even if the full period of pregnancy have not arrived. As a point of 
ethics, moreover, it is questionable if we are justified in anticipating the 



CESAREAN SECTION. 519 

date of so dangerous an operation, even by a few weeks, unless the bene- 
fit to be derived is very decided indeed. 

Escape of Lochia and other Fluid* into the Peritoneal Cavity. — One 
important cause of peritonitis is the escape of the lochia through the 
uterine incision into the cavity of the peritoneum, which there decom- 
pose and acr as an unfailing source of irritation. This may be prevented, 
to a great extent, by seeing that the os uteri is patulous, so as to afford 
a channel for the escape of discharges, and by closing the uterine wound 
by sutures. In addition, there is the danger arising from blood and 
liquor amnii escaping into the peritoneum and subsequently decompos- 
ing. There is little evidence that " la toilette du peritoine," on which 
ovariotomists now lay so much stress, has ever been particularly attended 
to in Cesarean operations. 

The Unhealthy Condition of the Patient is the Chief Source of Dan- 
ger. — The chief predisposing cause of these inflammations, however, 
must be looked for in the condition of the patient, just as asthenic 
inflammation in ovariotomy is most frequently met with in tho?e whose 
general health is broken down by the long continuance of the dis as •. 
We are fully justified, therefore, in assuming that peritonitis and metri- 
tis will be more likely to occur after the Cesarean section when that 
operation has been unnecessarily delayed and when the patient is 
exhausted by a protracted labor. In proof of this we find that in a 
large proportion of the cases above mentioned peritonitis occurred when 
the operation was performed under unfavorable conditions. 

Septiccemia. — The sources of septicaemia are abundantly evident — not 
the least, probably, being absorption by the open vess 1- in the uterine 
incision. 

Nervous Shock. — The last great danger is general shock to the nervous 
system. In Kayser's 123 cases, 30 of the death- are referred to this 
cause. In the large majority of these the patient was profoundly 
exhausted before the operation was begun. It is in predisposing to 
these nervous complications that we should, apriorij expect that vacil- 
lation and delay would be most hurtful ; and in operating when the 
patient's strength is still unimpaired we afford her the best chance of 
bearing the inevitable shock of an operation of such magnitude. 

Secondary Dangers. — In addition a few cases have been lost from 
accidental complications, which are liable to occur after any serious 
operation, and which do not necessarily depend on the nature of the 
procedure. 

J)<ni(jcr to Child from Portions of if* Body being C<ri/r/f,f by tin- Con- 
tracting Uterus. — There js only one source of danger special t<> the child 
which is worthy of attention. As the infant i- being removed from the 
cavity of the uterus the muscular parietes sometimes contract with 
rapidity and force, bo a- t<» seize and retain some part of it- body. This 
occurred in two of Dr. Radford's cases, and in one of them it i- stated 
that "the child was vigorously alive when first taken hold of, but from 
the length of time occupied in extracting the head it became so enfeebled 
as to -how only slight signs of life," and subsequently all attem] 
resuscitation failed. I have myself seen the head caught in this way, 
and so forcibly retained that a second incision was required to release it. 



520 OBSTETRIC OPERATIONS. 

In Dr. Radford's cases the placenta happened to be immediately under 
the incision, and he attributes the inordinate and rapid contraction of 
the uterus to its premature separation. It is difficult to believe that this 
was more than a coincidence, because the contraction does not take place 
until the greater part of the child's body has been withdrawn, and 
because numerous cases are recorded in which the uterus was opened 
directly over the placenta, or in which it was lying loose and detached, 
in none of which this accident occurred. The true explanation may, 
I think, be found in the varying irritability of the uterus in different 
cases. 

Irrespective of the risk of portions of the child being caught and 
detained, rapid contraction is a distinct advantage, since the danger of 
hemorrhage is thereby thus diminished. Serious consequences may be 
best avoided by removing, when practicable, the head and shoulders of 
the child first, or by employing both hands in extraction, one being 
placed near the head, the other seizing the feet. Either of these methods 
is preferable to the common practice of laying hold of the part that 
may chance to lie most conveniently near the line of incision. If this 
point were properly attended to, although the detention of the lower 
extremities might occasionally occur, the life of the child would not be 
imperilled. 

Whenever it is Possible the Patient should be Prepared for the Opera- 
tion. — The preparation of the patient for the operation should seriously 
occupy the attention of the practitioner ; and this is the more essential 
since almost all patients requiring the Csesarean section are in a 
wretchedly debilitated condition. If the patient be not seen until she is 
actually in labor, of course this is out of the question. But this will 
rarely be the case, since the deformed condition of the patient must 
generally have attracted attention. Every possible means should be 
taken, therefore, when practicable, to improve the general health by 
abundance of simple and nourishing diet, plenty of fresh air, and suit- 
able tonics (amongst which preparations of iron should occupy a promi- 
nent place), while the state of the secretions, the bowels, skin, and kid- 
neys should be specially attended to. Whenever it is possible a large, 
airy apartment should be selected for the operation, which should never 
be done in a hospital if other arrangements be practicable. These 
details may seem trivial and unnecessary ; but to ensure success in so 
hazardous an undertaking no care can be considered superfluous, and 
probably the want of attention to such points has had much to do with 
increasing the mortality. 

Question of Time to be Selected for the Operation. — The question arises 
whether we should operate before labor has commenced. By selecting 
our own time, as some have advised, we certainly have the advantage of 
operating under the most favorable conditions, instead of, possibly, hur- 
riedly. There are, however, numerous advantages in waiting until spon- 
taneous uterine action has commenced which seem to me to more than 
counterbalance the advantages of choosing our own time. Prominent 
among these is the partial opening of the os uteri, so as to afford a chan- 
nel for the escape of the lochia, and the certainty of active contraction 
of the uterus to arrest hemorrhage. Barnes recommends that premature 



CESAREAN SECTION. 521 

labor should be first induced, and then the operation performed. This 
seems to me to introduce a needless element of complexity ; and, besides, 
in cases of great deformity it is by no means always easy to reach the 
cervix with the view of bringing on labor. All needful arrangements 
should be made, so as to avoid hurry and excitement when the operation 
is commenced, and we may then wait patiently until labor has fairly 
set in. 

The Administration of Anaesthetics. — The operation itself is simple. 
The patient should be placed on a table in a good light, and with the 
temperature of the room raised to about Qo°. Chloroform has so fre- 
quently been followed by severe vomiting that it is probably better not 
to administer it. For the same reason Mr. Spencer Wells has long given 
up using it in ovariotomy, and finds that chloro-methyl answers admira- 
bly ; ether also is devoid of the disadvantages of chloroform. In one 
or two cases local anaesthesia has been used by means of two spray-pro- 
ducers acting simultaneously ; and this plan, if the patient have sufficient 
fortitude to dispense with general anaesthesia, has the further advantage 
of stimulating the uterus to powerful contraction. 

To ensure as great a measure of success as possible the operation 
should be performed under carbolic spray and with all the minute pre- 
cautions used in ovariotomy. 

Description of the Operation. — The incision should be made as much 
as possible in the line of the linea alba, so as to avoid wounding the 
epigastric arteries. On account of the deformity the configuration of 
the abdomen is often much altered, and some have advised that the 
incision should be made oblique or transverse and on the most promi- 
nent part of the abdomen. The risk of hemorrhage being thus much 
increased, the practice is not to be recommended. The incision, com- 
mencing a little above the umbilicus, is carried clown for about three 
inches below it. The skin and muscular fibres are carefully divided, 
layer by layer, until the shining surface of the peritoneum is readied, 
and any bleeding vessels should be secured as we proceed. A small 
opening is now made in the peritoneum, which should be laid open along 
the whole length of the incision upon two fingers of the left hand intro- 
duced as a guide. Before incising the uterus an assistant should care- 
fully support it in a proper position, and push it forward by the hands 
placed on either side of the incision, so as to bring its surface into apposi- 
tion with the external wound and prevent the escape of the intestines. 
If we have reason to believe that the placenta Is situated anteriorly, we 
may incise the uterus on one or other side; otherwise the line of incision 
should be as nearly as possible central. 1 The substance of the uterus is 
next divided until the membranes are reached, which are punctured and 
divided in the same way as the peritoneum. The uterine incision should 
be of the same length as that in the abdomen, and it should nol be 
made too near the fundus; for not only is that pari more vascular than 
the body of the uterus, but wounds in that situation are more api to 
gape, and do not cicatrize so favorably. A.fter the uterus is opened, I>r. 
L/udwig Winckel recommends that the fingers of an assistant should be 

[ l See Kehrer's plan of incising the uterus transversely for this purpose, on page 

524.— Ed.] 



522 OBSTETRIC OPERATIONS. 

placed in the two terminal angles of the wound, so that the ends of 
the incision may be hooked up and brought into close apposition with 
the abdominal opening. By this means he prevents not only the escape 
of blood and liquor amnii into the cavity of the peritoneum, but also 
the protrusion of the abdominal viscera. 

Removal of the Child. — The child should now be carefully removed, 
the head and shoulders being taken out (if possible) first; the placenta 
and membranes are afterward extracted. Should the placenta be unfor- 
tunately found immediately under the incision, a considerable loss of 
blood is likely to take place, which can only be checked by removing it 
from its attachments and concluding the operation as rapidly as possible. 

Importance of Securing Uterine Contraction. — As soon as the child 
and the secundines have been extracted the sooner the uterus contracts 
the better. It will usually do so of itself, but should it remain lax and 
flabby, it should be pressed and stimulated by the hand. We are spe- 
cially warned against handling the uterus by Ramsbotham and others, 
but there seems no valid reason why we should not restrain hemorrhage 
in this way, as after a natural labor. The intervention of the abdominal 
parietes in their lax condition after delivery can make very little differ- 
ence between the two cases. Ergotin administered hypodermically will 
also be useful in promoting efficient contraction. 

Closure of the Uterine and Abdominal Wounds. — The advisability of 
closing the uterine wound by sutures is a mooted point. [ T ] The balance 
of evidence is certainly in favor of this practice, as tending to prevent 
the escape of the lochia into the peritoneal cavity. Interrupted sutures 
of silver wire may be used and cut short, or, as successfully practised by 
Spencer Wells, a continuous silk suture may be applied, one end being 
passed through the os into the vagina, by which it is subsequently with- 
drawn. Sutures of ordinary catgut are apt to yield, and are therefore 
unreliable ; but chromic gut or some of the antiseptic guts now prepared 
may doubtless be used with safety. Before closing the uterine wound 
one or two fingers should be passed through the cervix to ensure its 
being patulous. A free escape of the lochia in this direction is of great 
consequence, and Winckel even advises the placing of a strip of lint 
soaked in oil in the os, so as to keep up a free exit for the discharge. 

The Abdominal Wound should not be Closed until Hemorrhage has 
Ceased. — A point of great importance, and not sufficiently insisted on, 
is the advisability of not closing the abdominal wound until we are 
thoroughly satisfied that hemorrhage is completely stopped, since any 
escape of blood into the peritoneum would very materially lessen the 
chances of recovery. In a successful case reported by Dr. Newman 2 the 
wound was not closed for nearly an hour. Before doing so all blood 
and discharges should be carefully removed from the peritoneal cavity 

\} Uterine sutures have been in use in the United States since June, 1828, but there 
were only 4 cases thus treated from 1828 to 1868, since which time there have been 
27, making 31 in all. Of these, 12 were sutured with silver wire, and 6 recovered ; 15 
with silk, and 4 were saved ; 1 with fine hemp, recovered ; 2 with catgut, lost ; and 1 
with an unnamed material, lost. Of the 28 early operations in the list of the United 
States, but 6 were sutured, saving 3 ; and of the balance, 22, there were 18 that recov- 
ered. — Ed.] 

2 Obst, Trans., vol. viii. 



CJESAREAS SECTION. 523 

by clean soft sponges dipped in warm water. The abdominal wound 
should be closed from above downward by harelip pins, wire or silk 
sutures, which should be inserted at a distance of an inch from each 
other and passed entirely through the abdominal walls and the perito- 
neum at some little distance from the edges of the incision, so as to 
bring the two surfaces of the peritoneum into contact. By this means 
we ensure the closure of the peritoneal cavity, the opposed surfaces 
adhering with great rapidity. If, as should be the case, the operation is 
performed with full antiseptic precautions, the wound should now be 
dressed precisely as after ovariotomy. 

Subsequent Management. — Into the subsequent treatment it is unneces- 
sary to enter at any length, since it must be regulated by general princi- 
ples, each symptom being met as it arises. It has been customary to 
administer opiates freely after the operation, but they seem to have a 
tendency to produce sickness and vomiting, and ought not to be exhib- 
ited unless pain or peritonitis indicates that they are required. In fact, 
the treatment should in no way differ from that usual after ovariotomy, 
and the principles that should guide us will be best shown by the follow- 
ing quotation from Mr. Spencer Wells's description of that operation : 
"The principles of after-treatment are — to obtain extreme quiet, com- 
fortable warmth, and perfectly clean linen to the patient; to relieve pain 
by warm applications to the abdomen and by opiate enemas; to give 
stimulants when they are called for by failing pulse or other sighs of 
exhaustion; to relieve sickness by ice or iced drinks; and to allow plain, 
simple, but nourishing food. The catheter must be used every six or 
eight hours until the patient can move without pain. The suture- are 
removed on the third day, unless tympanitic distension of the stomach 
or intestines endangers reopening of the wound. In such circumstances 
they may be left for some days longer. The superficial sutures may 
remain until union seems quite firm." 

[Improved Method* of Performing Gastro-hysterotomy. — These, with 
one exception — that of Dr. Garrigues of New York — come from Ger- 
many, where there is a disposition to revive the old Cesarean operation 
in consequence of that of Porro having saved in that country hut a frac- 
tion over 32 per cent, of the women. The new antiseptic processes are 
devised by Cohnstein and Kehrer of Heidelberg, Prank of Cologne, 
and Sanger of Leipzig. Cohnstein's' process has not yet been tested. 
He proposes to turn out the uterus entire; open it vertically through 
the posterior wall ; deliver the foetus and secundines; replace the organ, 
and pass a drainage-tube through the Douglas cul-de-sac and vagina . 
and close the abdominal wound. lie directs tliat compression of the 
aorta shall be made during the opening and contraction of the uterus 
to check the loss of blood. 

Frank's Process: 2 — Wash the abdomen over with ether and with a 5 
per cent, solution of carbolic acid; disinfecl the vagina by irrigating 
with the latter fluid. Turn out the uterus, and ojjen it vertically in 
front, commencing the incision low down in the vesico-uterine excava- 
tion ; extract the foetus and secundines ; wash the front of the uterus, its 

V- CentraJblatt fur Qynakol., 1881, CTo. L2, vol. v. p. 2:10.] 

[ 2 Ibid., 1881, No. 25, vol. v. p. 598.] 



524 OBSTETRIC OPERATIONS. 

interior, and the vagina with the 5 per cent, carbolic-acid solution. Pass 
a large drainage-tube through the abdominal and uterine wounds and out 
through the vagina. Suture the uterus above the tube ; draw the round 
ligaments together above the uterine wound, and secure them with sutures 
of Czerny silk, so as to close over and separate the vesico-uterine pouch 
from the abdominal cavity. Drainage is to be made by three tubes — 
" one utero-vaginal, one pre-uterine, and a third applied along the ute- 
rine wound to the top of the pavilion." This operation has been per- 
formed in the interest of the foetus upon a badly-burned woman, who 
survived for ten hours ; the child was saved. 

Kehrer's Process. 1 — In this form of operation the uterus is to be 
opened transversely and low down in front. After delivery close the 
muscular layer of the uterus by from six to ten deep-seated sutures of 
carbolized silk, and the peritoneal portion by from twelve to twenty-five. 
Use Listerism in the operation and dressings, abdominal drainage, and 
vaginal irrigation. This operation has been performed with entire success 
upon a malacosteon subject of 26 years of age. In a second case it resulted 
fatally, the wound in the uterus not having been thoroughly closed. 

Sanger's P?*ocess. 2 — After the abdominal incision is made insert two 
strong ligatures through the margins of the wound near its upper angle, 
to be drawn upon after turning out the uterus. Rupture the membranes 
through the vagina. If practicable, turn out the uterus and hold it 
vertically. A sheet of caoutchouc, moistened with a 5 per cent, carbolic- 
acid solution, is to be made to enclose the cervix and cover the abdomen 
as a protector, and the ligatures are to be drawn while the uterus is being 
incised vertically in front and evacuated. If the organ is incised in situ, 
manual compression is to be made upon its lower segment as a haemo- 
static. If turned out first, then the same, or the application of clamps 
to the broad ligaments or of an elastic tube to the cervix. After evacu- 
ating the uterus use haemostatic pincettes if the edges of the uterine 
wound bleed. When the uterus is well contracted pass a utero-vaginal 
drainage-tube, and introduce a carbolized sponge into the uterine cavity ; 
then dissect the peritoneum free from the muscular edges of the uterine 
wound, and pare from the latter on each side a long slice of tissue of a 
wedge shape, the thick edge being next to the peritoneal side. Turn in 
the free edges of the peritoneum over the muscular layer, and unite by 
deep-seated sutures of silver wire or silk ; then bring the serous sur- 
faces of peritoneum in contact, and secure them by numerous superficial 
sutures. 

Three operations under this method, performed by Dr. Leopold of 
Dresden, saved all the women and children, who continued in good 
health at the last report. A fourth case, under Dr. Beumer, was lost, as 
the subject was in bad health from cystitis and pyelo-nephritis, and sur- 
vived but forty hours ; the child was saved. At the late International 
Medical Congress of Copenhagen, Dr. Leopold expressed the opinion 
that in future operations he would be able to protect the abdominal 
cavity against uterine leakage without the resection by folding in the 
cut edges of the peritoneum in suturing the uterine wound. This was 

[} Archiv fur GynakoL, 1882, No. 2, vol. xix. p. 180.] 
[ 2 Ibid., 1882, No. 3, vol. xix. p. 397.] 



CESAREAN SECTION. 525 

proved on autopsy to have been accomplished in the operation of Dr. 
Garrigues of Xew York, performed on October 6, 1882. 1 The uterine 
wound was entirely united, but the woman, who lived 50 hours, never 
recovered from the effect of a severe ante-partum hemorrhage : her pulse 
at the time of the operation was 124. Two of the Leopold operations 
were performed since that of Dr. Garrigues. — Ed.] 

\_The Results of the Ccesarean Operation in Great Britain and the 
United States Compared. — The fear of, and opposition to, the operation 
in Great Britain are very natural results of the general fatality which 
has attended it, even when performed early and by the must skilful 
hands. It was for a long time claimed that the delay in operating con- 
stituted the chief cause of the mortality of the Cesarean section in the 
British Isles as compared to that on the Continent ; but this can be 
shown to be an error, as there have been operations enough performed 
in good season to prove that gastro-hysterotomy , per se, is very fatal to 
British women. I have elsewhere given a record of 28 early operations 
performed in the United States, showing a recovery of 75 per cent, of 
the women, 23 of the children being delivered alive. By a careful 
selection from the 138 British cases I have formed a table of 33 oj K-ra- 
tions, 23 of which were performed upon women not over twelve hours 
in labor, and 10 from twelve to eighteen hours ; and the results are as 
follows : 

Labor induced, 1 case; fatnl to the mother, child alive. 

Labor not commenced, 3 cases; 2 mothers recovered, children all living, 2 premature. 

Labor lasting from two to ten hours, inclusive, 11 cases; all fatal, 8 children alive. 

Kecorded as "early" 1 case; mother saved, child dead. 

Labor recorded as having been in progress a few hours; mother and child saved. 

Labor from eleven to sixteen hours, inclusive, 8 cases; 1 woman saved, 7 children 
alive. 

Labor from seventeen to eighteen hours, inclusive, 8 cases; 3 women saved, 5 chil- 
dren alive. 

Of the 33 cases, 25 averaged in labor eleven and a half hours, and 
but 4 of them were saved. There were 17 cases not exceeding ben 
hours in labor, of which 4 were saved; and 16 cases from eleven to 
eighteen hours in labor, and there were likewise 4 women saved. The 
mortality of the cases, even when seasonably operated upon, may there- 
fore be set down at 75 per cent., against 25 per cent, of like cases in the 
United States. The general average of recoveries in our country is now 
about 40 per cent. ; we therefore save more than 2 cases <<>r 1 that recov- 
ers in Great Britain; and of seasonable operations the recoveries are as 
3 to 1. This difference in our favor can only be accounted for by the 
difference of physical condition in the subjects. As in the United States 
and France the women of the farm and village are much more likely t<» 
recover than those of the cities, so Likewise the better fed and less intem- 
perate poor of our country have a decided advantage over their less-fav- 
ored sisters in England, where 81 per cent, have perished against <;•> per 
cent, in the United States. — Ed.] 

Porro's Operation. — Within the last few years an important modifi- 
cation of the Cesarean section has been adopted, which i- generally 
known as Porro's operation, from Professor rorro of Pavia, who was 

[ x American Journ. of Obstetrics, April, 1883, i>. 844.] 



526 OBSTETRIC OPERATIONS. 

the first European surgeon who practised it. In this operation, after 
the uterus is emptied, the entire organ is drawn out of the abdominal 
wound and excised, its neck being first constricted so as to suppress 
hemorrhage, the stump being fixed externally in the manner of the 
pedicle in ovariotomy. The idea is by no means new. It appears to 
have been first suggested by an Italian — Dr. Cavallini — in 1768. In 
1823 the late Dr. Blundell made the same proposal, and fortified it 
by numerous experiments on pregnant rabbits, in the course of which 
he found that he lost all by the Cesarean section, but saved 3 out of 4 
in which he ligatured and amputated the uterus. The suggestion was 
not, however, carried into actual practice until Dr. Storer of Boston in 
1869 removed the uterus in a case of fibroid tumor obstructing the 
pelvis and impeding delivery. 

Since Porro's first case the operation has been frequently performed 
on the Continent, with results which are, on the whole, encouraging. 
The cases have been carefully tabulated by Dr. Harris of Philadelphia, 
and more recently, and very completely, by Dr. Clement Godson, 1 who 
has collected 138 cases, out of which 61, or 55.8 per cent., were success- 
ful as regards the mother. This result is certainly superior to those fol- 
lowing the Cesarean section as ordinarily performed. The obvious 
advantage of this plan is that instead of leaving the incised uterus with 
its probably gaping wound and all the attendant risk of septic mischief 
in the abdominal cavity, it is fixed externally, and in a position where it 
can be readily dressed. 

The objection is that it entirely unsexes the patient, but in the class 
of women requiring the Csesarean section from pelvic deformity it is 
questionable whether this can be fairly considered as a drawback. It is 
perhaps not justifiable to attempt as yet any positive decision as to the 
indications for this plan, but it seems beyond doubt that the risks are 
considerably less than those of the Csesarean section. 

The Operation. — The operation in the successful cases has been per- 
formed under the carbolic spray, and the neck of the uterus, after the 
organ is emptied, carefully secured by ligatures before its body is ampu- 
tated. Some operators have encircled the neck of the uterus with a 
chain or wire £craseur before removing it, and by this means completely 
controlled hemorrhage. Richardson 2 transfixed the neck of the uterus 
with two large pins crossing each other before removing the wire of the 
6craseur, and encircled them with stout carbolized cord. Mtiller of 
Berne has recommended that the entire uterus should be turned out of 
the abdominal cavity through a long incision before it is emptied, so as 
to avoid the risk of its fluid contents entering the abdomen ; but this 
manoeuvre has not always proved feasible. The pedicle has generally 
been fixed in the lower angle of the abdominal wound and dressed anti- 
septically. In most cases one or more drainage-tubes have been used, 
either through Douglas's space or in the abdominal wound. 

[Latest Porro- Cesarean Statistics. 3 — Dr. Clement Godson of London 
has recently added 15 cases to his former tabular record of 137, and 

1 Porro's Operation, Brit. Med. Journ., Jan. 26, 1884. 

2 American Journ. of Med. Science, Julv, 1881. 
[ 8 Brit. Med. Journ., Jan. 47, 1885, p. 120.] 



CESAREAN SECTION. 527 

thereby increased it to 152, and Dr. Ettore Truzzi 1 of Milan has ob- 
tained by correspondence 12 more, making the whole 164 cases, saving 
69 women and 129 children. The average number of operations per 
annum for the past five years has been 25 ; those of 1884, as far as ascer- 
tained, amount to 23, with only 9 women saved, although 19 children 
were living. Of the 164 cases, 109 were operated upon by the method 
of Porro, many of them very unfavorable, and 46 were saved ; 41 by 
the modification of Mil Her, with 21 recoveries ; and 14 by that of Veit, 
of dropping in the stump, with 10 deaths. In 6 cases the Muller method 
failed of completion after making the long incision, and the operations 
were completed by the plan of Porro, by which 4 were saved. Of 16(3 
children extracted (2 women bore twins), 129 were " living," but not in 
a moribund condition, and 37 were dead or moribund. The Italian ope- 
rators saved 53 out of 69 children; the Germans saved 18, and lost 10; 
the Austrians 32, and lost 3 ; the French 10, and lost 5 ; English and 
Scotch 6, and lost 3 ; the United States 2, and lost 1 ; Belgians 4, lost 
0; and Swiss 2, lost 0. 

The operations in private houses number 23, of which 10 recovered 
and 13 died. The best hospital work was done in Milan, where five 
operators in Santa Caterina saved 10 women out of 13, and all of the 
children. In the Krankenhaus of Vienna, 13 women and 23 children 
were saved by 26 operations. By excluding 3 moribund cases and the 
14 Veit experiments from the 164 operations, leaving the Porro and 
Porro-Muller cases only, we have 147, saving 65 women, or 44 per 
cent. ; which I now regard as the true status of the " Porro operation." 
These may be subdivided into 90 favorable cases, of which 53 recovered, 
or 58 T 3 y per cent. ; and 57 unfavorable, of which only 13 were saved, or 
less than 23 per cent. 

The greatest degree of success has been attained in Austria, where 
nine operators saved 20 out of 34 women, or nearly 59 per cent. Under 
forty-three operators in Italy, 28 out of 65 women were saved, or 43J- 
per cent. Germany, under sixteen operators, lost 19 out of 28, and 4 
of the 9 saved were by Dr. Fehling of Stuttgart, who lost only 1 oul of 
his 5 eases. France saved 5 out of 15, and Great Britain 1 out of 9. 
In this enumeration no case is counted where the foetus was non-viable. 
Prof. Breisky of Prague saved all of his 5 cases, and Prof. Porro him- 
self 4 out of 5.— Ed.] 

Substitute for the Ccesarean Section. — Bearing in mind the greal mor- 
tality attending the Csesarean section, it is not surprising thai obstetri- 
cians should have anxiously considered the possibility of devising a sub- 
stitute which should afford the mother a better elm nee of recovery. The 
first proposal of the kind was one from which great results were at first 
anticipated. In 1768, Sigault, then a student of medicine in Paris, sug- 
gested symphyseotomy, which consists in the division of the symphysis 
pubis, with a view of allowing the pubic bones to separate sufficiently 
to admit of the passage of the child. Although at firsl strongly opposed, 
it was subsequently ardently advocated by many obstetricians, and was 
often performed on the Continent and in a few cases in this country. 

The Operation is Admitted to be Useless. — It is generally admitted 

[} Annali Universal! di Medicina, Milano, Oct., 1884, p. 387, and Nov., 1884, p. 401.] 



528 OBSTETRIC OPERATIONS. 

that it is quite impossible to make this a substitute for the Cesarean 
section, since the utmost gain which even a wide separation of the sym- 
physis pubis would give would be altogether insufficient to admit of the 
passage of even a mutilated foetus. Dr. Churchill concludes that even 
if it were possible to separate it to the extent of four inches, we should 
only have an increase of from four lines to half an inch in the antero- 
posterior diameter, in which the obstruction is generally most marked. 
In the lesser degrees of deformity this might possibly be sufficient to 
allow the foetus to pass, but the risk of the operation itself and the 
subsequent ill-effects altogether -contraindicate it in cases of this 
description. 

[Possibilities of Gastro-hysterotomy. — Old as it is, the Cesarean opera- 
tion is still upon trial, and has by no means attained the minimum of 
mortality of which it is capable under modern improvements as one of 
the forms of abdominal surgery. The Porro method has demonstrated 
the importance of securing the abdominal cavity against the entrance of 
septic matters escaping from the uterine wound ; and its modification by 
Yeit, of dropping in the pedicle, with its far greater fatality, has only 
tended to confirm our opinion as to the importance of preventing all 
uterine leakage. But is there no way of rendering the uterine wound 
as water-tight as that made in the stomach in gastrotomy when secured 
by the suture of Gely ? We believe there is. When the peritoneal coat 
of the uterus is so stitched, in securing the uterine wound, as to make it 
form a welt, with its serous surfaces brought in contact, as in the Gely 
suture, the local adhesive peritonitis which follows will soon effectually 
secure the wound against the possibility of fluid passing through it. 
This was demonstrated very satisfactorily in the Garrigues case, already 
quoted, although the previous condition of the woman gave it a fatal 
termination ; and also in that of Drs. Drysdale in Philadelphia and 
Jewett in Brooklyn. The results of the three Leopold operations show 
more decidedly the value of the improvement, having all recovered. 
As far as ascertained by autopsy, the serous surfaces will unite within 
thirty hours, provided the uterine muscular tissue is sufficiently firm in 
texture to enable the deep-seated sutures to hold and prevent gaping. 
To secure this condition of soundness it is important to operate early, as 
it is also to save the strength of the patient, and thus secure her against 
shock and septic peritonitis. The past record of the operation in the 
United States clearly demonstrates the value of an early use of the 
knife, and the future ought to show better results when all the addi- 
tional precautions recently introduced are made use of. In a large pro- 
portion of American cases we would not be justified in removing the 
uterus, as under the Porro method, and it is therefore important to 
diminish the risks of the old operation. It is also to be considered, in 
view of past success, whether an improved Csesarean section will not 
promise better results than the dangerous expedient of craniotomy and 
evisceration in cases where the foetus is impacted in a transverse posi- 
tion. These considerations are purely national, as the records of Great 
Britain give very little encouragement for performing gastro-hysterot- 
omy. The fact that 25 children were delivered alive from 33 women 
operated upon within eighteen hours after the commencement of labor 



LAPARO-ELYTROTOMY. 529 

shows that the cases were not lost by delay; yet 25 of these women were 
lost — a number which we should expect to save in this country. — Ed.] 

\_The revival of symphyseotomy in Italy, and its greatly improved 
results, show that the large mortality of the early cases, and especially 
of the children, was due to the foetus having been either turned or forci- 
bly delivered before its head had time to become moulded to the form 
of the superior strait, the value of which process is set forth by the 
author on page 397, chap. xii. I do not regard so much the gain in 
the conjugate diameter as that in the transverse in symphyseotomy : 
certain it is that the new operation, wherein the foetus is delivered by 
the forces of the mother in the large majority of cases, is far less fatal to 
her and the foetus than the original one, where the child was turned and 
forced into the world by traction, to its fatal injury, and the injury of 
the woman by the strain upon her sacro-iliac symphyses. Under Pro- 
fessors O. Morisani and Novi of Naples 43 women and 42 children were 
saved by 53 symphyseotomies from 1866 to 1881. "Symphyseotomy 
can never be made to take the place of the Csesarean section in cases of 
extreme deformity, as its advocates are not inclined to recommend it in 
cases having a conjugate of less measure than 67 millimeters, or 2| 
inches." 

For a full exposition of the subject see Harris on the " Revival of 
Symphyseotomy in Italy" in Am. Joum. of Med. Sci. for Jan., 1883 ; 
also "Una Probabile Risurrezione nel Campo Dell' ostetricia opera- 
tiva," in the Annali d' Ostetricia, anno v., 1883, by Prof. Mangiagalli 
of the University of Sassari, Italy. — Ed.] 



CHAPTER VII. 

LAPAKO-ELYTROTOMY. 



In the former editions of this work laparo-elytrotomy was briefly con- 
sidered as one of the suggested substitutes for the Csesarean section which 
merited careful study and appeared to be of a promising character, but of 
which too little was known to justify any positive conclusions with regard 
to it. The subject naturally attracted considerable attention, and several 
interesting papers have appeared in which its indications, difficulties, and 
advantages have been carefully considered. Since Thomas's first case 
was published several operations have been performed} with results so 
encouraging that I cannot but believe that the operation has a great 
future before it, and that it will be the duty of the accoucheur t<» n sort 
to it instead of the more hazardous Cesarean section, unless some special 
contraindication exists. Under these circumstances it seems proper no 
longer to consider it as an addendum to the description of the < Cesarean 
section, but to study it more in detail in a separate chapter. 

History. — The history of the operation is curious and interesting. 
34 



530 OBSTETRIC OPERATIONS. 

The earliest suggestion of a procedure of this character seems to have 
been made by Joerg in the year 1806, who proposed a modified Cesa- 
rean section, without incision of the uterus, by the division of the linea 
alba and of the upper part of the vagina, the foetus being extracted 
through the cervix. This suggestion was never carried into practice, 
and it is obvious that it misses the one chief advantage of laparo-elytrot- 
omy, the leaving of the peritoneum intact. In 1820, Bitgen proposed, 
and actually attempted, an operation much resembling Thomas's, in 
which section of the peritoneum was avoided. He failed, however, to 
complete it, and was eventually compelled to deliver his patient by the 
Cesarean section. In 1823, Baudelocque the younger independently 
conceived the same idea, and actually carried it into practice, although 
without success. Lastly, in 1837, Sir Charles Bell suggested a similar 
operation, clearly perceiving its advantages. Hence it appears that pre- 
vious to Thomas's recent work in the matter the operation was inde- 
pendently invented no less than three times. It fell, however, entirely 
into oblivion, and was only occasionally mentioned in systematic works 
as a matter of curious obstetric history, no one apparently appreciating 
the promising character of the procedure. 

In the year 1870, Dr. T. Gaillard Thomas of New York read a paper 
before the Medical Association of the town of Yonkers on the Hudson 
River, entitled " Gastro-elytrotomy, a Substitute for the Cesarean Sec- 
tion," in which he described the operation as he had performed it three 
times on the dead subject and once on a married woman in 1870, with a 
successful issue as regards the child. It seems beyond doubt that Thomas 
invented the operation for himself, being ignorant of Bitgen's and Bau- 
delocque's previous attempts, and it is certain, to quote Garrigues, 1 that 
to him " belongs the glory of having been the first who performed gas- 
tro-elytrotomy so as to extract a living child from a living mother in his 
first operation, and of having brought both mother and child to complete 
recovery in his second operation." 

Since Thomas's first case the operation has been performed three 
times by Dr. Skene of Brooklyn, and has found its way across the 
Atlantic, having been twice performed in England, by Hime in Shef- 
field and by Edis in London. [ 2 ] 

Nature of the Operation. — The object of laparo-elytrotomy is to reach 
the cervix by incision through the lower part of the abdominal wall and 
upper part of the vagina, and through it to extract the foetus as may 
most easily be done. 

Advantages over the Cwsarean Section. — If this procedure is found 
practicable, the enormous advantages it offers over the Cesarean section 
are at once apparent, since in dividing the abdomen the abdominal wall 

1 New York Med. Journ., Nov., 1878. 

[ 2 Thomas operated twice; Skene four times; Charles Jewett of Brooklyn twice; 
Hime, Edis, Dandridge and Taylor of Cincinnati, and Walter R. Gillette of New 
York, each once ; in all, 12. Women saved, 6 ; children living, but not moribund, 7 ; 
bladder lacerated in 6 cases. In properly calculating the risks of the operation it is 
fair to exclude the moribund case of Thomas, the intemperate and bedridden one of 
Hime, and the diseased subject of Edis, who survived, respectively, one hour, two 
hours, and forty hours. The balance, 9 cases, were favorable in 4 instances and unfav- 
orable in 5 : 6 of the 9 women recovered, and 5 children were saved.] 



LAPARO-EL YTR0T03IY. 531 

only is incised and the peritoneum is left intact. The vagina is divided, 
but incision of the uterine parietes, which forms one of the chief risks 
of the Csesarean section, is entirely avoided. Now, there is nothing in 
either of these procedures alarming in itself, and if further experience 
proves that the practical difficulties of the operation do not stand in the 
way of its adoption, Dr. Thomas will have introduced, by his able advo- 
cacy of the operation, probably the greatest improvement in modern 
obstetrics. 

Cases Suitable for the Operation. — It may be broadly stated that 
laparo-elytrotomy is applicable in all cases calling for the Csesarean sec- 
tion when the mother is alive. In post-mortem extractions ?>f the fetus 
the Csesarean section, being the most rapid procedure, would certainly be 
preferable. Exceptions must be made for certain cases of morbid con- 
ditions of the soft parts which render delivery per vias naturales impos- 
sible, and in which laparo-elytrotomy could not be performed, as in cases 
of tumor obstructing the pelvic cavity, also in carcinoma or fibroid of 
the uterus. When the head is firmly impacted in the pelvic brim and 
cannot be dislodged, the operation would be impossible, as the vagina 
could not be incised. Unlike the Csesarean section, the operation cannot 
be performed twice on the same patient, at least on the same side, since 
adhesions left by the former incisions would prevent the separation of 
the peritoneum and division of the vagina. It remains to be seen 
whether in certain cases of extreme deformity, with pendulous abdomen 
and distorted thighs, the site of incision might not be so difficult to reach 
as to render the necessary manoeuvres impossible. 

It will facilitate the proper comprehension of the operation, and ren- 
der an avoidance of its possible dangers more easy, if the anatomical 
relations of the parts concerned are briefly described. 

Abdominal Incision. — The abdominal incision extends from a point 
an inch above the anterior-superior iliac spine, and is carried, with a 
slight downward curve, parallel to Poupart's ligament until it reaches ;i 
point one inch and three-quarters above, and to the outside of, the spine 
of the pubes. Beyond the latter point it must not extend, so as to avoid 
the risk of wounding the round ligament and the epigastric artery. In 
this incision the skin, the aponeurosis of the external oblique, and the 
fibres of the internal oblique and transversalis muscles are divided. The 
rectus is not implicated. After the muscles are divide* 1 the transversalis 
fascia is reached. It is fortunately rather dense in this situation, and 
is separated from the peritoneum by a layer of connective tissue contain- 
ing fit. 

Arteries. — The superficial epigastric artery is necessarily divided, but 
is too small to give any trouble. The internal epigjastric is fortunately 
not divided, but is so near the inner end of the incision thai il ma} acci- 
dentally be so. In one of Dr. Skene's operations it was laid bare. 
Starting from the external iliac, about a quarter of an inch above Pou- 
parfs ligament, it runs downward, forward, and inward t«» the ligament ; 
thence it turns upward and inward in front of the round ligament and 
to, the inner side of the internal abdominal ring, behind the posterior 
layer of the sheath of the rectus muscle, which it finally enters. The 
circumflex iliac artery also rises from the external iliac a little below the 



532 OBSTETRIC OPERATIONS. 

epigastric. It runs between the peritoneum and Poupart's ligament 
until it reaches the crest of the ilium, to the inner side of which it runs. 
It thus lies altogether below the line of the incision, and is not likely to 
be injured. 

Peritoneum. — After the transversalis fascia is divided the peritoneum 
is reached, and is readily lifted up intact, so as to expose the upper part 
of the vagina, through which the foetus is extracted. It is fortunate, as 
facilitating this manoeuvre, that the peritoneum is much more lax than 
in the non-pregnant state, and it has been found very easy to lift it out 
of the way in all the operations hitherto performed. 

Vaginal Incision. — The division of the vagina is the part of the ope- 
ration likely to give rise to most trouble and risk. It is to be noted 
that in cases of pelvic contraction calling for this operation the uterus, 
with its contents, will be abnormally high and altogether above the pel- 
vic brim ; the vagina is therefore necessarily elongated and brought more 
readily wkhin reach. It is enlarged in its upper part during pregnancy, 
and thrown into folds ready for dilatation during the passage of the 
child. It is loosely surrounded by the other tissues, and is composed of 
muscular fibres, easily separable, and an internal mucous layer. Its 
vascular arrangements are very complex, and the risk of hemorrhage 
is one of the prominent difficulties of the operation. 

In Baudelocque's attempt, in which the vagina was cut instead of 
torn, the loss of blood was so great as to lead to a discontinuance of the 
operation. The arteries are numerous, consisting of branches from the 
hypogastric, inferior vesical, internal pudic, and hemorrhoidal. The 
veins form a network surrounding the whole canal, but are largest at 
its extremities, so that it is desirable to open the vagina as low down as 
possible. 

Relations of the Vagina. — Behind the vagina lies the pouch of perito- 
neum known as Douglas's space, and below that the rectum. In front 
of it lies the bladder, and the risk of injuring that viscus or the ureter 
entering it constitutes another of the dangers of the operation. The 
relations of these parts have been specially studied by Garrigues l with 
the view of facilitating the safe performance of the operation, and I 
quote his description : 

" The anterior-superior surface of the vagina is, in its upper part, 
bound by loose connective tissue to the bladder on a surface that has the 
shape of a heart. In the lower or anterior part the boundary-line of 
this surface runs parallel to and a little outside of the trigonum vesicate. 
In the upper part it follows the outline of the vagina, from which it 
passes over to the cervix. The distance from the internal opening of the 
urethra to the neck of the womb is one inch and a quarter (3.2 centi- 
meters). The bladder extends five-eighths of an inch (1.5 centimeters) 
upon the cervix. It is very liable to be reached by the vaginal rent if 
the latter is made too high up or too horizontal. The lower part of the 
antero-superior wall carries in the middle line the urethra. In the 
uppermost part, a little outside of and behind the bladder, lies the ureter. 
In order to avoid the ureter and the bladder, the incision of the vagina 
should be made nearly an inch and a half (3.8 centimeters) below the 

1 Log. cit., p. 479. 



LAPARO-EL YTR0T03IY. 533 

uterus, and in a direction parallel to the ureter and the boundary-line 
between the bladder and the vagina." 

The Operation. — The operation has hitherto been performed on the 
right side only. In consequence of the position of the rectum on the 
left, it seems doubtful if the difficulties of performing it on that side 
would not render the operation impossible. This point can only be 
cleared up by experience, and in the mean time the right side should cer- 
tainly be selected. For the proper performance of the operation four 
assistants are necessary, besides one who administers the anaesthetic. 
The patient is placed on her back on the operating-table, with pelvis 
raised and in the same position as for ovariotomy. In consequence of 
access of air per vaginam strict antiseptic precautions cannot be adopted. 
Before commencing the operation the cervix is dilated as much as pos- 
sible by Barnes's bags, assisted, if necessary, by digital dilatation. 

The operator stands on the right side of the patient, while an assist- 
ant, standing on her left, lays his hand on the uterus and draws it up- 
ward and to the left, so as to put the skin on the stretch. The incision 
is commenced at a point one inch above the anterior-superior spine of 
the ilium, and is carried inward, in a slightly curved direction, until it 
reaches a point one and three-quarter inches above and outside the spine 
of the pubes. The skin and muscular and aponeurotic tissues are care- 
fully divided, layer by layer, any arterial branches being secured as they 
are severed, until the transversafis fascia is reached. This is raised by a 
fine tenaculum, and an aperture is made in it, through which a director 
is introduced, and on this the fascia is divided in the whole length of 
the superficial incision. The operator now separates the peritoneum from 
the transversalis and iliac fascia with his fingers, and an assistant, placid 
on his left, elevates it, as well as the contained intestines, by means of a 
fine warmed napkin, and keeps it well out of the way during the rest 
of the operation. A third assistant now introduces a silver catheter into 
the bladder, and holds it in the position of the boundary-line between it 
and the vagina and below the uterus. 

A blunt wooden instrument like the obturator of a speculum i- intro- 
duced into the vagina, which is pushed up by it above the ilio-pectineal 
line. On this an incision is made by Paquelin's thermo-cautery, heated 
to a red heat only, as far below the uterus as possible, and parallel t<> the 
ilio-pectineal line and the catheter felt in the bladder. When the vagina 
has been burnt through, the index fingers of both hands are push d 
through the incision, and the vagina torn through as for forward :i~ i- 
deemed safe by the guide of the catheter in the bladder and a- far back- 
ward as possible. When this has been done the uterus is depressed l" 
the left and the cervix lifted into the incision by the fingers, and the 
membranes are ruptured. Through the cervix thus elevated the child is 
extracted, according to the presentation, either by simple traction, by the 
forceps, or by turning. Before concluding the operation the Madder 
should be injected with milk, to make sure that it hasnol been wounded. 
Should it be so, the laceration may be :it once united by carbolized gut 
The principal risk at this stage is hemorrhage Prom the vaginal vessels, 
which, however, fortunately did not give rise t<» much trouble in any <>f 
the recent operations. If it occurs, it musl !»«' dealt with as best we can, 



534 OBSTETRIC OPERATIONS. 

either by ligature, by the actual cautery, or by thoroughly plugging the 
vaginal wound with cotton wool both through the incision and per 
vaginam. If the latter be not necessary, the wound should be cleaned 
by injecting a warm solution of weak carbolized water (2 per cent.), its 
edges united by interrupted sutures, and dressed as is deemed best. The 
subsequent treatment must be conducted on general surgical principles, 
and will much resemble that necessary after other severe abdominal 
operations, such as ovariotomy. The vagina should be gently syringed 
two or three times daily with a weak antiseirtic lotion. The diet should 
be light and nutritious, chiefly consisting of milk, beef-tea, and the like. 
Pain, pyrexia, etc. must be treated as they arise. 

[Laparo-elytrotomy has been performed but four times since January, 
1880. The skill and number of assistants it requires must necessarily 
limit its adoption. It may be performed with equal facility on the left 
side, as was shown in 1878 by the operation of Dr. Hime in England, 
and in 1883 by that under Drs. Danclridge and Taylor of Cincinnati, in 
neither of which cases was the bladder injured. Dr. Taylor prefers the 
left-side operation as more convenient than the right. In 57 of the 134 
Csesarean operations of the United States laparo-elytrotomy would have 
been impracticable. — Ed.] 



CHAPTER VIII. 

THE TRANSFUSION OF BLOOD. 

The transfusion of blood in desperate and apparently hopeless cases 
of hemorrhage offers a possible means of rescuing the patient which 
merits careful consideration. It has again and again attracted the atten- 
tion of the profession, but has never become popularized in obstetric 
practice. The reason of this is not so much the inherent defects of the 
operation itself — for quite a sufficient number of successful cases are 
recorded to make it certain that it is occasionally a most valuable 
remedy — but the fact that the operation has been considered a delicate 
and difficult one, and that it has been deemed necessary to employ a 
complicated and expensive apparatus which is never at hand when a 
sudden emergency arises. Whatever may be the difference of opinion 
about the value of transfusion, I think it must be admitted that it is of 
the utmost consequence to simplify the process in every possible way ; 
and it is above all things necessary to show that the steps of the opera- 
tion are such as can be readily performed by any ordinarily qualified 
practitioner, and that the apparatus is so simple and portable as to make 
it easy for any obstetrician to have it at hand. There are comparatively 
few who would consider it worth while to carry about with them, in 
ordinary every-day work, cumbrous and expensive instruments which 
may never be required in a lifelong practice ; and hence it is*not unlikely 
that in many cases in which transfusion might have proved useful the 



THE TRANSFUSION OF BLOOD. 535 

opportunity of using it has been allowed to slip. Of late years the 
operation has attracted much attention, the method of performing it has 
been greatly simplified, and I think it will be easy to prove that all the 
essential apparatus may be purchased for a few shillings, and in so port- 
able a form as to take up little or no room, so that it may be always 
carried in the obstetric bag ready for any possible emergency. 

History of the Operation. — The history of the operation is of con- 
siderable interest. In Villari's Life of Savonarola it is said to have 
been employed in the case of Pope Innocent VIII. in the year 1492, 
but I am not aware on what authority the statement is made. The first 
serious proposals for its performance do not seem to have been made 
until the latter half of the seventeenth century. It was first actually 
performed in France by Denis of Montpellier, although Lower of Oxford 
had previously made experiments on animals which satisfied him that it 
might be undertaken with success. In Xovember, 166 7, some months 
after Denis's case, he made a public experiment at Arundel Hon.^e, in 
which twelve ounces of sheep's blood were injected into the veins of a 
healthy man, who is stated to have been very well after the operation ; 
which must therefore have proved successful. These nearly simultane- 
ous cases gave rise to a controversy as to priority of invention which 
was long carried on with much bitterness. 

The idea of resorting to transfusion after severe hemorrhage doe- not 
seem to have been then entertained. It was recommended as a means 
of treatment in various diseased states or with the extravagant hope of 
imparting new life and vigor to the old and decrepit. The blood of the 
lower animals only was used ; and under these circumstances it i- not 
surprising that the operation, although practised on several occasions, 
was never established as it might have been had its indications beeu 
better understood. 

From that time it fell almost entirely into oblivion, although experi- 
ments and suggestions as to its applicability were occasionally made, 
especially by Dr. Harwood, Professor of Anatomy at Cambridge, who 
published a thesis on the subject in the year 1785. He, however, n iver 
carried his suggestions into practice, and, like his predecessors, only pro- 
posed to employ blood taken from the lower animals. In the year L82 L, 
Dr. Blundell published his well-known work entitled Researches, Physio- 
logical find Pathological, which detailed a large number of experiments ; 
and to that distinguished physician belongs the undoubted merit of hav- 
ing brought the subject prominently before the profession and of pointing 
out the cases in which the operation might be performed with hopes of 
3S. Since the publication of this work transfusion has been regarded 
as a legitimate operation under special circumstances; but, although it 
ha- frequently been performed with success, and in spite of many inter- 
esting monographs on the subject, it has never bee • so established ;i- 

a general resource in suitable cases a- it- advantages would seem t<> war- 
rant. Within the last few years more attention has been paid t<» the 
subject, and the writings of Panum, Martin, and De Belina abroad, and 
of Higginson, McDonnell, Hick-, Aveling, and Schafer at home, am 
others, have thrown much light on many point- connected with the 
operation. 



536 OBSTETRIC OPERATIONS. 

Nature and Object of the Operation. — Transfusion is practically only 
employed in cases of profuse hemorrhage connected with labor, although 
it has been suggested as possibly of value in certain other puerperal con- 
ditions, such as eclampsia or puerperal fever. Theoretically , it may be 
expected to be useful in such diseases, but, inasmuch as little or nothing 
is known of its practical effects in these diseased states, it is only possi- 
ble here to discuss its use in cases of excessive hemorrhage. Its action 
is probably twofold : 1st, the actual restitution of blood which has been 
lost ; 2d, the supply of a sufficient quantity of blood to stimulate the 
heart to contraction, and thus to enable the circulation to be carried on 
until fresh blood is formed. The influence of transfusion as a means of 
restoring lost blood must be trivial, since the quantity required to pro- 
duce an effect is generally very small indeed, and never sufficient to 
counterbalance that which has been lost. Its stimulant action is no 
doubt of far more importance, and if the operation be performed before 
the vital energies are entirely exhausted the effect is often most marked. 

Use of Blood taken from the Lower Animals. — In the earliest opera- 
tions the blood used was always that of the lower animals, generally of 
the sheep. It has been thought by Brown-Sequard and others that the 
blood of some of the lower animals, especially of those in which the cor- 
puscles are of smaller size than in man, as of the sheep, might be used 
with safety, provided it is not too rich in carbonic acid and too poor in 
oxygen, and injected in small quantity only. Landois, 1 however, has 
conclusively proved that the blood of any of the lower animals has a 
most injurious effect on the human red corpuscles, which rapidly become 
swollen and decolorized and discharge their coloring matter into the 
serum. It is certain, therefore, that this plan cannot be adopted in 
practice. 

Difficulties from Coagulation of Fibrin. — The great practical difficulty 
in transfusion has always been the coagulation of the blood very shortly 
after it has been removed from the body. When fresh-drawn blood is 
exposed to the atmosphere, the fibrin commences to solidify rapidly — 
generally in from three to four minutes, sometimes much sooner. It is 
obvious that the moment fibrillation has commenced the blood is, ipso 
facto, unfitted for transfusion, not only because it can be no longer 
passed readily through the injecting apparatus, but because of the great 
danger of propelling small masses of fibrin into the circulation and thus 
causing embolism. Hence, if no attempt be made to prevent this diffi- 
culty, it is essential, no matter what apparatus is used, to hurry on the 
operation so as to inject before fibrillation has begun. This is a fatal 
objection, for there is no operation in the whole range of surgery in 
which calmness and deliberation are so essential, the more so as the sur- 
roundings of the patient in these unfortunate cases are such as to tax 
the presence of mind and coolness of the practitioner and his assistants 
to the utmost. 

Methods of Obviating Coagulation. — All the recent improvements have 
had for their object the avoidance of coagulation ; and practically this has 
been effected in one of three ways : 1st, by immediate transfusion from 
arm to arm, without allowing the blood to be exposed to the atmosphere, 

1 Die Transfusion des Blules, Leipsic, 1875. 



THE TRANSFUSION OF BLOOD. 537 

according to the methods proposed by Aveling, Roussel, and Schafer ; 
2d, by adding to the blood certain chemical reagents which have the 
property of preventing coagulation ; 3d, removal of the fibrin entirely, 
by promoting its coagulation and straining the blood, so that the liquor 
sanguinis and blood-corpuscles alone are injected. 

Inasmuch as the success of the operation altogether depends on the 
method adopted, it will be well, before going farther, to consider briefly 
the advantages and disadvantages of each of these plans. 

Immediate Transfusion : Aveling' 's 3Iethod. — The method of immediate 
transfusion has been brought prominently before the profession by Dr. 
Aveling, Avho has invented an ingenious apparatus for performing it. 
The apparatus consists essentially of a miniature Higginson's syringe 
without valves, and with a small silver canula at either end. One 
canula is inserted into the vein of the person supplying blood, the other 
into a vein of the patient, and by a curious manipulation of the syringe, 
subsequently to be described, the blood is carried from one vein into the 
other. It must be admitted that if there were no practical difficulties 
this instrument would be admirable; and it is therefore not surprising 
that it should have met with so much favor from the profession. I can- 
not but think, however, that the operation is not so simple as at first sight 
appears, and that therefore it wants one of the essential elements required 
in any procedure for performing transfusion. One of my objections is 
that it is by no means easy to work the apparatus without considerable 
practice. Of this I have satisfied myself by asking members of my class 
to work it after reading the printed directions, and finding that they arc 
not always able to do so at once. Of course it may be said that it is 
easy to acquire the necessary manipulative skill; but when the necessity 
for transfusion arises there is no time left for practising with the instru- 
ment, and it is essential that an apparatus to be universally applicable 
should be capable of being used immediately and without previous 
experience. Other objections are the necessity of several assistants, 
the uncertainty of there being a sufficient circulation of blood in the 
veins of the donor to afford a constant supply, and the possibility of the 
whole apparatus being disturbed by restlessness or jactitation on the 
part of the patient. For these reasons it seems to me that this plan of 
immediate transfusion is not so simple nor so generally applicable as 
defibrination. Still, it is impossible not to recognize its merits, and it i- 
certainly well worthy of further study and investigation. 

Roussel' s Method. — Another method of immediate transfusion is t lint 
recommended by Roussel, 1 whose apparatus has recently attracted con- 
siderable attention. It possesses many undoubted advantages, and k 
beyond doubt, a valuable addition to our means of performing \\w ope- 
ration. It has, however, the great disadvantage of being costly and com- 
plicated, and hence I do not believe that it i> likely to come Into general 

use. 

Sch dfer's Method. — The third method is that recommended by Dr. 
Schafer in his recent excellent reports on transfusion submitted to the 
Obstetrical Society. 2 Schafer suggests two methods of performing the 

operation — one from vein to vein, the other from artery l<> artery. I he 
1 Obstetrical Transactions, vol. xviii. 2 Ibid., vol. sxi. 



538 OBSTETRIC OPERATIONS. 

latter, he holds, has the advantage of supplying pure oxygenated blood 
under the best possible conditions for securing the amelioration of a 
patient suffering from the effects of profuse hemorrhage. The necessary 
operative proceedings are, however, somewhat complicated, and it seems 
to me very doubtful if this plan is likely to be at all commonly used. 
His method of immediate transfusion, however, is very simple, and is 
well worthy of trial. In his experiments on the lower animals it an- 
swered admirably. I am not aware that it has yet been tried on the 
human subject, but I do not see any practical difficulty in its applica- 
tion. For the description of the operation I have inserted Dr. Schafer's 
own directions for the performance of both arterial and venous imme- 
diate transfusion. 

Addition of Chemical Agents to Prevent Coagulation. — The second 
plan for obviating the bad effects of clotting is the addition of some 
substance to the blood which shall prevent coagulation. It is well 
known that several salts have this property, and the experiments made 
in the case of cholera patients prove that solutions of some of them may 
be injected into the venous system without injury. This method has 
been specially advocated by Dr. Braxton Hicks, who uses a solution of 
three ounces of fresh phosphate of soda in a pint of water, about six 
ounces of which are added to the quantity of blood to be injected. He 
has narrated 4 cases 1 in which this plan was adopted successfully, so far 
as the prevention of coagulation was concerned. It certainly enables the 
operation to be performed with deliberation and care, but it is somewhat 
complicated ; and it may often happen that the necessary chemicals are 
not at hand. A further objection is the bulk of fluid which must be 
injected ; and there is reason to believe that this has in some cases seri- 
ously embarrassed the heart's action and interfered with the success of 
the operation. In many of the successful cases of transfusion the amount 
of blood injected has been very small, not more than two ounces. Dr. 
Richardson proposes to prevent coagulation by the addition of liquor 
ammoniee to the blood, in the proportion of two minims diluted with 
twenty minims of water to each ounce of blood. 

Defibrination of the Blood. — The last method, and the one which, on 
the whole, I believe to be the simplest and most effectual, is defibrina- 
tion. It has been chiefly practised in this country by Dr. McDonnell 
of Dublin, who has published several very interesting cases in which he 
employed it, and abroad by Martin of Berlin and De Belina of Paris. 
The process of removing the fibrin is simple in the extreme, and occu- 
pies a few minutes only. Another advantage is that the blood to be 
transfused may be prepared quietly in an adjoining apartment, so that 
the operation may be performed with the greatest calmness and delibera- 
tion, and the donor is spared the excitement and distress which the sight 
of the apparently moribund patient is apt to cause, and which, as Dr. 
Hicks has truly pointed out, may interfere with the free flow of blood. 
The researches of Panum, Brown-Sequard, and others have proved that 
the blood-corpuscles are the true vivifying element, and that defibrinated 
blood acts as well, in every respect, as that containing fibrin. It has 
been proved that the fibrin is reproduced within a short time, 2 and the 

1 Guy's Hospital Reports, vol. xiv. 2 Panum, Virchow's Arch., vol. xxvii. 



THE TRANSFUSION OF BLOOD. 539 

whole tendency of modern research is to regard it not as an essential ele- 
ment of the blood, but as an excrementitious product, resulting from the 
degradation of tissue ; which may therefore be advantageously removed. 
Another advantage derived from defibrination is, that the corpuscles are 
freely exposed to the atmosphere, oxygen is taken up, and carbonic acid 
given off, and the dangers which Brown-Sequard has shown to arise 
from the use of blood containing too much carbonic acid are thereby 
avoided. There can be, therefore, no physiological objection to the 
removal of the fibrin, which, moreover, takes away all practical difficul- 
ty from the operation. The straining to which the defibrinated blood is 
subjected entirely prevents the possibility of even the most minute par- 
ticle of fibrin being contained in the injected fluid ; the risk from embo- 
lism is therefore less than in any of the other processes already referred 
to. My own experience of this plan is limited to 3 cases, but in 2 it 
answered so well that I can conceive no reasonable objection to it. I 
should be inclined to say that transfusion, thus performed, is amongst 
the simplest of surgical operations — an opinion which the experience of 
McDonnell and others fully confirms. 

Transfusion of Milk. — Recently the intra-venous injection of freshly- 
drawn warm milk has been recommended as a substitute for blood, 
chiefly in America. It was first used by Dr. Hodder of Toronto, but 
has been introduced and strongly advocated by Thomas of Xew York, 
who has used it twice after ovariotomy. Brown-Sequard in experi- 
menting on the lower animals found that it answered as well as either 
fresh or defibrinated blood, and about half an hour after the injection 
no trace of the milk-corpuscles could be found in the blood. Schafer, 
however, found that the action of milk on the blood-corpuscles was 
highly deleterious, and that it introduces the germs of septic organisms 
likely to produce very serious results. He therefore pronounces strongly 
against its use. 

Statistical Results. — The number of cases of transfusion are perhaps 
not sufficient to admit of completely reliable conclusions. It is certain, 
however, that transfusion has often been the means of rescuing the 
patient when apparently at the point of death and alter all other means 
of treatment had failed. Professor Martin records 57 cases, in I") of 
which transfusion was completely successful, and in 7 temporarily so, 
while in the remaining 7 no reaction took place. Dr. Higginson of 
Liverpool has had 15 cases, 10 of which were successful. Figures such 
as these are encouraging, and they are sufficienl to prove that the opera- 
tion is one which at least offers a fair hope of success, and which no 

obstetrician would be justified in neglecting when the patient is sinking 
from the exhaustion of profuse hemorrhage. It is t<> bo hoped also 
that further experience may prove it to be of value in other cases in 
which its use has been suggested, but not, as yet, put to tin- test of 
experiment. 

Possible Dangers <>f the Operation. — The possible risks of the opera- 
tion would seem to be the danger of injecting minute particles of fibrin 

which form emboli, of bubbles of air, or of overwhelming the action <>f 
the heart by injecting too rapidly or in too great quantity. These may 
be, to a great extent, prevented by careful attention to the proper per- 



540 OBSTETRIC OPERATIONS. 

formance of the operation, and it does not clearly appear, from the 
recorded cases that they have ever proved fatal. We must also bear in 
mind that transfusion is seldom or never likely to be attempted until 
the patient is in a state which would otherwise almost certainly preclude 
the hope of recovery, and in which, therefore, much more hazardous 
proceedings would be fully justified. 

Cases Suitable for Transfusion. — The cases suitable for transfusion are 
those in which the patient is reduced to an extreme state of exhaustion 
from hemorrhage during or after labor or miscarriage, whether by the 
repeated losses of placenta prsevia or the more sudden and profuse flood- 
ing of post-part urn hemorrhage. The operation will not be contem- 
plated until other and simpler means have been tried and failed, or until 
the symptoms indicate that life is on the verge of extinction. If the 
patient should be deadly pale and cold, with no pulse at the wrist or one 
that is scarcely perceptible ; if she be unable to swallow, or vomits 
incessantly ; if she lie in an unconscious state ; if jactitation or convul- 
sions or repeated fainting should occur ; if the respiration be laborious 
or very rapid and sighing ; if the pupil do not act under the influence 
of light, — it is evident that she is in a condition of extreme danger, and 
it is under such circumstances that transfusion, performed sufficiently 
soon, offers a fair prospect of success. It does not necessarily follow 
because one or other of these symptoms is present that there is no chance 
of recovery under ordinary treatment, and indeed it is within the expe- 
rience of all that patients have rallied under apparently the most hope- 
less conditions. But when several of them occur together the prospect 
of recovery is much diminished, and transfusion would then be fully 
justified, especially as there is no reason to think that a fatal result has 
ever been directly traced to its employment. Indeed, like most other 
obstetric operations, it is more likely to be postponed until too late to be 
of good service than to be employed too early ; and in some of the cases 
reported as unsuccessful it was not performed until respiration had 
ceased and death had actually taken place. It has sometimes been said 
that transfusion should never be employed if the uterus be not firmly 
contracted, so as to prevent the injected blood again making its escape 
through the uterine sinuses. The cases in which this is likely to occur 
are few ; and if one were met with the escape of blood could be pre- 
vented by the injection into the uterus of the perchloride of iron. 

Description of the Operation. — In describing the operation I shall 
limit myself to an account of Aveling's and Schafer's method of imme- 
diate transfusion and to that of injecting clefibrinated blood. I consider 
myself justified in omitting any account of the numerous instruments 
which have been invented for the purpose of injecting pure blood, since 
I believe the practical difficulties are too great ever to render this form 
of operation serviceable. The great objection to most of them is their 
cost and complexity, and as long as any special apparatus is considered 
essential the full benefits to be derived from transfusion are not likely 
to be realized. The necessity for employing it arises suddenly ; it may 
be in a locality in which it is impossible to procure a special instru- 
ment ; and it would be well if it were understood that transfusion may 
be safely and effectually performed by the simplest means. In many 



THE TRAXSFUSIOy OF BLOOD. 



541 



of the successful cases an ordinary syringe was used ; in one, in the 
absence of other instruments, a child's toy syringe was employed. I 
have myself performed it with a simple syringe purchased at the near- 
est chemist's shop when a special transfusion apparatus failed to act sat- 
isfactorily. 

Method of Performing Immediate Transfusion. — In immediate trans- 
fusion (Fig. 190) the donor is seated close to the patient, and the veins 

Fig. 190. 




Method of Transfusion by Aveling's Apparatus. 

in the arms of each having been opened, the silver canula at either end 
of the instrument is introduced into them (a b). The tube between the 
bulb and the donor is now pinched (d), so as to form a vacuum, and the 
bulb becomes filled with blood from the donor. The finger is now- 
removed so as to compress the distal tube (d'), and, the bulb being com- 
pressed (c), its contents are injected into the patient's vein. The bulb 
is calculated to hold about two drachms, so that the amount injected can 
be estimated by the number of times it is emptied. The risk of inject- 
ing air is prevented by filling the syringe with water, which is injected 
before the blood. 

Schafer's Directions for Immediate Transfusion. — " Procure two glass 
canulas of appropriate size and shape (see Fig. 191), and a piece of black 
india-rubber tubing seven inches long and not less than a 
quarter of an inch bore, fitted to the canulas. This appara- 
tus could always be improvised. 

Procedure. — " Place the transfusion-tube in a basin of 
hot w r ater containing a little carbonate of soda. Put a 
tape round the arm of the patient just below the place 
where the vein is to be opened and another just aoove. 
Expose the vein by an incision through the -kin, which 
should be made transversely if the position of the vein 
cannot be made out through the skin. Clear a -mall 
piece of the vein with forceps and -lip a pointed piece of 
card underneath it. By a snip with scissors make an 
oblique opening into the vein, and partly insert a small 
blunt instrument (such as a wool-needle), so that the aper- 
ture is not lost. Remove the upper tape. Nexl prepare tin vein of the 



Fig. 191, 




542 OBSTETRIC OPERATIONS. 

giver. To do this put tapes around the arm just below and above the 
place where the vein is to be opened. Expose the vein by a longitudinal 
incision through the skin. Clear a small piece of the vessel with for- 
ceps and pass a thread ligature underneath. A slip of card may also be 
placed under this vein. Make a snip into the vein just above the liga- 
ture, and then, taking the transfusion-tube out of the soda solution, slip 
one of the canulas into the vein of the giver, and tie it in with a simple 
knot which can be readily untied. Let the giver go to the bedside and 
place his arm alongside that of the patient. Hold the end of the india- 
rubber tube with the second canula up a little, and release the lower 
tape on the arm of the blood-giver. As -soon as blood flows out of 
the second canula pinch the india-rubber tube close to the canula, 
so as to stop the flow, and, removing the wool-needle, slip the end 
of the canula into the vein of the patient, hold it there, and allow 
the blood to pass freely along the tube. Three minutes will generally 
be long enough for the flow, which can be stopped by compressing 
the vein of the giver below the canula. Both canulas may now be 
withdrawn and the ligature removed from the vein of the giver, the 
cut veins being dealt with in the usual way. Of course the other tape 
on the arm of the donor must be removed as soon as the transfusion 
is over. 

" Instead of using the transfusion-tube empty, it may be filled with 
soda solution, to the exclusion of air. It is necessary to have one or 
two spring clips on the tube to prevent the escape of the solution. This 
is a much better plan than the other, for the blood need not be allowed 
to flow into the tube until the second canula is inserted, and then, by 
opening the clips, it may drive the soda solution before it into the vein. 
The small quantity of carbonate-of-soda solution necessary to fill the 
simple tube will do the patient no harm. 

Direct Centripetal Arterial Transfusion. — " In the first place, we have 
to determine what artery or arteries would be most available for the pur- 
pose. The (left) radial artery could be most easily dealt with, and its 
use would involve less subsequent inconvenience to the donor of the 
blood than any other. But if it is considered necessary to choose some 
other artery, I think the dorsal artery of the foot should be selected, for 
its employment presents several advantages. It is a minor artery, but 
nevertheless large enough for the insertion of a canula ; it is compara- 
tively superficial and pretty easily found ; and by causing the person 
yielding the blood to stand up a great amount of pressure may be 
obtained in it, In the bloodless patient, especially if there be much 
subcutaneous fat, this artery might not be readily found. 

Apparatus Required. — "A piece of india-rubber tubing six or seven 
inches long, two glass canulas of appropriate size and shape, and some 
spring clips, two of which should be small for compressing the arteries, 
the others larger and adapted for clipping the tube. The smaller clips 
might be dispensed with, and ligatures fastened with a slip bow might 
be used instead, in the way Lower recommended. Before commencing 
it is important to ensure that the india-rubber tube cannot slip off the 
canulas. It ought to be secured to them by tight ligatures or by bind- 
ing wire. This precaution is necessary because the arterial blood is under 



THE TRANSFUSION OF BLOOD. 543 

considerable pressure. This would tend to force the tubes apart and 
might cause copious hemorrhage. 

" The transfusion-tube is to be placed as before in carbonate-of-soda 
solution. 

Procedure. — " The artery of the patient must first be exposed. To do 
this make an incision an inch in length through the skin over the line 
of the artery, and then divide to an equal extent the subcutaneous tissue 
and fascia which cover it. About three-quarters of an inch in length 
of the vessel is to be separated from the ensheathing connective tissue 
and from its accompanying veins by slipping a blunt instrument, such 
as an aneurism-needle or the blade of a forceps, underneath and moving 
it up and down. A small piece of card, cut into a long triangular shape, 
may then be placed under instead of the needle. A ligature is then tied 
tightly around the lower end of the jDiece of artery, another is looped 
loosely around the middle, and a spring clip is put on close to the upper 
end. The vessel may now be opened just above the lower ligature by a 
snip with the scissors. 

" If the artery have any branch at the exposed part, this ought to be 
tied before commencing to isolate the vessel. In the person who is to 
yield the blood exactly the same process is carried out. 

" The transfusion-tube is next filled (by suction) with soda solution, 
and this is prevented from escaping by one or two spring clips on the 
tube. 

"One of the glass terminals is tied into the artery of the giver and 
the other into the artery of the patient, the ends of both being directed 
toward the .heart. 

"All is now ready for the transfusion. To eifect this, remove the clip- 
on the india-rubber tube and open the clip on the artery of the patient ; 
then open — not remove — that on the artery of the giver, and keep it 
open one minute, or a little longer if it seems advisable. Allow the clips 
to close again, and if the patient's condition is ameliorated the operation 
may be ended by tying the arteries — first that of the giver, then that of 
the patient — -just above the clips. 

"Finally, cut out and remove the canulas, together with the pieces of 
artery into which they are tied." 

Injection of Defibrinated Blood. — For injecting defibrinated blood 
various contrivances have been used. McDonnell's instrument is a sim- 
ple cylinder with a nozzle attached, from which the blood i< propelled 
by gravitation. When the propulsive power is insufficient, increased 
pressure is applied by breaking forcibly into the open end of the receiver. 
De Belina's instrument is on the same principle, only atmospheric pres- 
sure is supplied by a contrivance similar to Richardson's spray-producer, 
attached to one end. The idea is simple, but there ie some doubt of a 
gravitation instrument being sufficiently powerful, and it certainly failed 
in my hands. I have had valves applied to Aveling's instrument, so 
that it works by compression of the bulb like an ordinary Higginson's 
syringe. This, with a single silver canula at one end for introduction 
into the vein, forms a perfect and inexpensive transfusion-apparatus, 
taking up scarcely any space. If it be not at hand, any small syringe 
with a tolerably fine nozzle may be used. 



544 OBSTETRIC OPERATIONS. 

Mode of Preparing the Blood. — The first step of the operation is 
defibrination of the blood, which should, if possible, be prepared in an 
apartment adjoining the patient's. The blood should be taken from the 
arm of a strong and healthy man. The quality cannot be unimportant, 
and in some recorded cases the failure of the operation has been attrib- 
uted to the fact of the donor having been a weakly female. The sup- 
ply from a woman might also prove insufficient ; and, although it has 
been shown that blood from two or more persons may be used with 
safety, yet such a change necessarily causes delay, and should, if possi- 
ble, be avoided. A vein having been opened, eight or ten ounces of 
blood are withdrawn, and received into some perfectly clean vessel, such 
as a dessert finger-glass. As it flows it should be briskly agitated with 
a clean silver fork or a glass rod, and very shortly strings of fibrin 
begin to form. It is now strained through a piece of fine muslin, previ- 
ously dipped in hot water, into a second vessel which is floating in 
water at a temperature of about 105°. By this straining the fibrin and 
all air-bubbles resulting from the agitation are removed, and if there 
be no excessive hurry it might be well to repeat the straining a second 
time. If the vessel be kept floating in warm water, the blood is pre- 
vented from getting cool, and we can now proceed to prepare the arm of 
the patient for injection. 

Mode of Exposing the Veins selected for Transfusion. — This is the 
most delicate and difficult part of the operation, since the veins are gen- 
erally collapsed and empty and by no means easy to find. The best way 
of exposing them is that practised by McDonnell, who pinches up a fold 
of the skin at the bend of the elbow, and transfixes it with a fine tenot- 
omy-knife or scalpel, so making a gaping wound in the integument, at 
the bottom of which they are seen lying. A probe should now be passed 
underneath the vein selected for opening, so as to avoid the chance of its 
being lost at any subsequent stage of the operation. This is a point of 
some importance, and from the neglect of this precaution I have been 
obliged to open another vein than that -originally fixed on. A small 
portion of the vein being raised with the forceps, a nick is made into it 
for the passage of the canula. 

Injection of the Blood. — The prepared blood is now brought to the 
bedside, and, the apparatus having been previously filled with blood to 
avoid the risk of injecting any bubbles of air, the canula is inserted into 
the opening made in the vein and transfusion commenced. It should be 
constantly borne in mind that this part of the operation should be con- 
ducted with the greatest caution, the blood introduced very slowly, and 
the effect on the patient carefully watched. The injection may be pro- 
ceeded with until some perceptible effect is produced, which will gener- 
ally be a return of the pulsation, first at the heart, and subsequently at 
the wrist, an increase in the temperature of the body, greater depth and 
frequency of the respirations, and a general appearance of returning 
animation about the countenance. Sometimes the arms have been 
thrown about or spasmodic twitchings of the face have taken place. 
The quantity of blood required to produce these effects varies greatly, 
but in the majority of cases has been very small. Occasionally 2 
ounces have proved sufficient, and the average may be taken as ranging 



THE TRAXSFVSIOS OF BLOOD. 545 

between 4 and 6, although in a few cases between 10 and 20 have been 
used. The practical rule is to proceed very slowly with the injection 
until some perceptible result is observed. Should embarrassed or fre- 
quent respiration supervene, we may suspect that we have been injecting 
either too great a quantity of blood or with too much force and rapidity, 
and the operation should at once be suspended, and not resumed until 
the suspicious symptoms have passed away. It may happen that the 
effects of the transfusion have been highly satisfactory, but that in the 
course of time there is evidence of returning syncope. This may possi- 
bly be prevented by the administration of stimulants, but if these fail 
there is no reason why a fresh supply of blood should not again be 
injected, but this should be done before the effects of the first transfusion 
have entirely passed away. 

Secondary Effects of Transfusion. — The subsequent effects in success- 
ful cases of transfusion merit careful study. In some few cases death is 
said to have happened within a few weeks with symptoms resembling 
pyaemia. Too little is known on this point, however, to justify any 
positive conclusions with regard to it. 

35 



PART V. 

THE PUERPERAL STATE. 



CHAPTER I. 

THE PUEBPERAL STATE AND ITS MANAGEMENT. 

Importance of Studying the Puerperal State. — The key to the manage- 
ment of women after labor, and to the proper understanding of the many 
important diseases which may then occur, is to be found in a study of 
the phenomena following delivery and of the changes going on in the 
mother's system during the puerperal period. No doubt natural labor 
is a physiological and healthy function, and during recovery from its 
effects disease should not occur. It must not be forgotten, however, 
that none of our patients are under physiologically healthy conditions. 
The surroundings of the lying-in woman, the effects of civilization, of 
errors of diet, of defective cleanliness, *of exposure to contagion, and of 
a hundred other conditions which it is impossible to appreciate, have 
most important influences on the results of childbirth. Hence it follows 
that labor, even under the most favorable conditions, is attended with 
considerable risk. 

The Mortality of Childbirth. — It is not easy to say with accuracy what 
is the precise mortality accompanying childbirth in ordinary domestic 
practice, since the returns derived from the reports of the Registrar- 
General or from private sources are manifestly open to serious error. 
The nearest approach to a reliable estimate is that made by Dr. Mat- 
thews Duncan, 1 who calculates, from figures derived from various sources, 
that no fewer than 1 out of every 120 women, delivered at or near the 
full time, dies within four weeks of childbirth. This indicates a mor- 
tality far above that which has been generally believed to accompany 
childbearing under favorable circumstances. It, however, closely ap- 
proximates to a similar estimate made by McClintock, 2 who calculates 
the mortality in England and Wales as 1 in 126, and in the upper and 
middle classes alone, where the conditions may naturally be supposed to 
be more favorable, at 1 in 146 ; more recently he has come to the con- 
clusion, from his own increased experience and the published results of 
the practice of others, that 1 in 100 would more correctly represent the 
rate of puerperal mortality. 3 In these calculations there are some obvi- 
ous sources of error, since they include deaths from all causes within 

1 The "Mortality of Childbed," Edin. Med. Journ., Nov., 1869. 

2 Dublin Quarterly Journ., Aug., 1869. 3 Brit. Med. Journ., Aug. 10, 1878. 

546 



THE PUERPERAL STATE AXB ITS MANAGEMENT. 547 

four weeks of delivery, some of which must have been independent of 
the puerperal state. 

But it is not the deaths alone which should be considered. All prac- 
titioners know how large a number of their patients suffer from morbid 
states which may be directly traced to the effects of childbearing. It is 
impossible to arrive at any statistical conclusion on this point, but it 
must have a very sensible and important influence on the health of 
childbearing women. 

Alterations in the Blood after Deliver}/. — The state of the blood during 
pregnancy, already referred to (p. 140), has an important bearing on the 
puerperal state. There is hyperinosis, which is largely increased by the 
changes going on immediately after the birth of the child ; for then the 
large supply of blood which has been going to the uterus is suddenly 
stopped, and the system must also get rid of a quantity of eifete matter 
thrown into the circulation in consequence of the degenerative changes 
occurring in the muscular fibres of the uterus. Hence all the depura- 
tive channels by which this can be eliminated are called on to act with 
great energy. If, in addition, the peculiar condition of the generative 
tract be borne in mind — viz. the large open vessels on its inner surface, 
the partially bared inner surface of the uterus, and the channels for 
absorption existing in consequence of slight lacerations in the cervix or 
vagina — it is not a matter of surprise that septic diseases should be so 
common. 

Condition after Delivery. — It will be well to consider successively the 
various changes going on after delivery, and then we shall be in a better 
position for studying the rational management of the puerperal state. 

Nervous Shock. — Some degree of nervous shock or exhaustion i- ob- 
servable after most labors. In many cases it is entirely absent, in others 
it is well marked. Its amount is in proportion to the severity of the 
labor and the susceptibility of the patient; and it is therefore mosl likely 
to be excessive in women who have suffered greatly from pain, who have 
undergone much muscular exertion, or who have been weakened from 
undue loss of blood. It is evidenced by a feeling of exhaustion and 
fatigue, and not uncommonly there is some shivering, which soon passes 
off, and is generally followed by refreshing sleep. The extreme nervous 
susceptibility continues for a considerable time alter delivery, and indi- 
cates the necessity of keeping the lying-in patient as free from all sources 
of excitement as possible. 

Fall of the Pulse. — Immediately after delivery the pulse falls; and 
the importance of this, as indicating a favorable state of the patient, has 
already been alluded to. The condition of the pulse has been carefully 
studied by Blot, 1 who has shown that this diminution, which he believes 
to It- connected with a diminished ten-ion in the arteries due to th< 
(h'n i\w(><t of the uterine circulation, continues in a large proportion of 
cases for a considerable number of days after delivery ; and :i- m matter 
of clinical import as Ion-- as it does the patieri may be considered t" '"■ 
in a favorable state. In many instances the slowness of the pub'- ifl 
remarkable, often sinking to 50, or even in, beats per minute. Any 
increase above the normal rate, especially if ;it nil continuous, should 

l Arch. gin. >/>- MSd., [864. 



548 THE PUERPERAL STATE. 

always be carefully noted and looked on with suspicion. In connection 
with this subject, however, it must be remembered that in puerperal 
women the most trivial circumstances may cause a sudden rise of the 
pulse. This must be familiar to every practical obstetrician who has 
constant opportunities of observing this effect after any transient excite- 
ment or fatigue. In lying-in hospitals it has generally been observed 
that the occurrence of any particularly bad case will send up the pulse 
of all the other patients who may have heard of it. 

Temperature in the Puerperal State. — The temperature in the lying-in 
state affords much valuable information. During and for a short time 
after labor there is a slight elevation. It soon falls to, or even some- 
what below, the normal level. Squire found that the fall occurred 
within twenty-four hours, sometimes within twelve hours, after the ter- 
mination of labor. 1 For a few days there is often a slight increase of 
temperature, especially toward the evening, which is probably caused by 
the rapid oxidation of tissue in connection with the involution of the 
uterus. In about forty-eight hours there is a rise connected with the 
establishment of lactation amounting to one or two degrees over normal 
level, but this again subsides as soon as the milk is freely secreted. Crede 
has also shown 2 that rapid but transient rises of temperature may occur 
at any period, connected with trivial causes, such as constipation, errors 
of diet, or mental disturbances. But if there be any rise of temperature 
which is at all continuous, especially to over 100° F., and associated 
with rapidity of the pulse, there is reason to fear the existence of some 
complication. 

The Secretions and Excretions. — The various secretions and excretions 
are carried on with increased activity after labor. The skin especially 
acts freely, the patient often sweating profusely. There is also an abun- 
dant secretion of urine, but not uncommonly a difficulty of voiding it, 
either on account of temporary paralysis of the neck of the bladder, 
resulting from the pressure to which it has been subjected, or from swell- 
ing and occlusion of the urethra. For the same reason the rectum is 
sluggish for a time, and constipation is not infrequent. The appetite is 
generally indifferent, and the patient is often thirsty. 

Secretion of Milk. — Generally in about forty-eight hours the secretion 
of milk becomes established, and this is occasionally accompanied by a 
certain amount of constitutional irritation. The breasts often become 
turgid, hot, and painful. There may or may not be some general dis- 
turbance, quickening of pulse, elevation of temperature, possibly slight 
shivering, and a general sense of oppression, which are quickly relieved 
as the milk is formed and the breasts emptied by suckling. Squire says 
that the most constant phenomenon connected with the temperature is a 
slight elevation as the milk is secreted, rapidly falling when lactation is 
established. Barker noted elevation either of temperature or pulse in 
only 4 out of 52 cases which were carefully watched. There can be 
little doubt that the importance of the so-called " milk fever " has been 
immensely exaggerated, and its existence as a normal accompaniment of 
the puerperal state is more than doubtful. It is certain, however, that 

1 " Puerperal Temperatures," Obstetrical Transactions, vol. ix. 
2 Monat. f. Geburt, Dec., 1868. 



THE PUERPERAL STATE AXD ITS MANAGEMENT. 549 

in a small minority of cases there is an appreciable amount of disturb- 
ance about the time that the milk is formed. Out of 423 cases, Macan 1 
found that in 114, or about 27 per cent., there was no rise in tempera- 
ture ; in 226 the temperature did rise to 100° and over, and of these in 
32, or a little over 7 per cent., the only ascertainable cause was a painful 
or distended condition of the breast. Many modern writers, such a.s 
Winckel, Grunewaldt, and D'Espine, entirely deny the connection of 
this disturbance with Jactation, and refer it to a slight and transient 
septicaemia. Graily Hewitt remarks that it is most commonly met with 
when the patient is kept low and on deficient diet after delivery, (Spe- 
cially when the system is below par from hemorrhage or any other cause. 
This observation will no doubt account for the comparative rarity of 
febrile disturbance in connection with lactation in these days, in which 
the starving of puerperal patients is not considered necessary. It is cer- 
tain that anything deserving the name of milk fever is now altogether 
exceptional, and such feverishness as exists is generally quite transient. 
It is also a fact that it is most apt to occur in delicate and weakly 
women, especially in those w T ho do not or are unable to nurse. There 
does not, however, seem to be any sufficient reason for referring it, even 
when tolerably well marked, to septicaemia. The relief which attends 
the emptying of the breasts seems sufficient to prove its connection with 
lactation, and the discomfort which is necessarily associated with the 
swollen and turgid mammae is of itself quite sufficient to explain it. 

Sugar in the Urine. — In the urine of women during lactation an 
appreciable amount of sugar may readily be detected. The amount 
varies according to the condition of the breasts. It increases when 
they are turgid and congested, and is therefore most abundant in women 
in whom the breasts are not emptied, as when the child is dead or when 
lactation is not attempted. 

Contraction of the Uterus after Delivery. — Immediately alter delivery 
the uterus contracts firmly, and can be felt at the lower part of the abdo- 
men as a hard, firm mass about the size of a cricket-ball. After a time 
it again relaxes somewhat, and alternate relaxations and contractions go 
on at intervals for a considerable time after the expulsion of the placenta. 
The more complete and permanent the contraction, the greater the safety 
and comfort of the patient; for when the organ remains in a state of 
partial relaxation coagula are apt to be retained in its cavity, while f « >i* 
the same reason air enters more readily into it. Hence decomposition is 
favored and the chances of septic absorption are much increased, while 
even when this does not occur the muscular fibres are excited t<> contraci 
and severe after-pains are produced. 

Subsequent Dimi n ution in the Size of the Ulerus. — After the first few 
days the diminution in the size of the uterus progresses with great rapid- 
ity. By about the sixth davit is - "<-\i lessened as to project not 

more than 1.} or 2 inches above the pelvic brim, while by the eleventh 
davit is no longer to be made out by abdominal palpation. It- in- 
creased size is, however, still apparent per vaginam, and should occasion 
arise for making internal examination, the mass "l" the lower segment 
of the uterus, with its flabby and patulous cervix, can be lilt for some 
1 Dublin .Jmirn. of Med. Science, May, 181 



550 THE PUERPERAL STATE. 

weeks after delivery. This may sometimes be of practical value in cases 
in which it is necessary to ascertain the fact of recent delivery, and 
under these circumstances, as pointed out by Simpson, the uterine sound 
would also enable us to prove that the cavity of the uterus is consider- 
ably elongated. Indeed, the normal condition of the uterus and cervix 
is not regained until six weeks or two months after labor. These obser- 
vations are corroborated by investigations on the weight of the organ at 
different periods after labor. Thus, Heschl 1 has* shown that the uterus 
immediately after delivery weighs about 22 to 24 oz., within a week it 
weighs 19 to 21 oz., and at the end of the second week 10 to 11 oz. only. . 
At the end of the third week it weighs 5 to 7 oz., but it is not until the 
end of the second month that it reaches its normal weight. Hence it 
appears that the most rapid diminution occurs during the second week 
after delivery. 

Fatty Transformation of the Muscular Fibres. — The mode in which 
this diminution in size is effected is by the transformation of the muscu- 
lar fibres into molecular fat, which is absorbed into the maternal vascular 
system, which therefore becomes loaded with a large amount of effete 
material. Heschl has shown that the entire mass of the enlarged uterine 
muscles are removed, and replaced by newly- formed fibres, which com- 
mence to be developed about the fourth week after delivery, the change 
being complete about the end of the second month. Generally speaking, 
involution goes on without interruption. It is, however, apt to be inter- 
fered with by a variety of causes, such as premature exertion, intercur- 
rent disease, and, very probably, by neglect of lactation. Hence the 
uterus often remains large and bulky, and the foundation for many sub- 
sequent uterine ailments is laid. 

Changes in the Uterine Vessels. — Williams has drawn attention to 
changes occurring in the vessels of the uterus, some of which seem to be 
permanent, and may, should further observations corroborate his inves- 
tigations, prove of value in enabling us to ascertain whether a uterus is 
nulli parous or the reverse — a question which may be of medico-legal 
importance. After pregnancy he found all the vessels enlarged in calibre. 
The coats of the arteries are thickened and hypertrophied, and this he 
has observed even in the uteri of aged women who have not borne chil- 
dren for many years. The venous sinuses, especially at the placental 
site, have their walls greatly thickened and convoluted, and contain in 
their centre a small clot of blood (Fig. 192). This thickening attains 
its greatest dimensions in the third month after gestation, but traces of it 
may be detected as late as ten or twelve weeks after labor. 

Changes in the Uterine Mucous Membrane. — The changes going on in 
the lining membrane of the uterus immediately after delivery are of 
great importance in leading to a knowledge of the puerperal state, and 
have already been discussed when describing the decidua (p. 104). Its 
cavity is covered with a reddish-gray film formed of blood and fibrin. 
The open mouths of the uterine sinuses are still visible, more especially 
over the site of the placenta, and thrombi may be seen projecting from 
them. The placental site can be distinctly made out in the form of an 
irregularly oval patch, where the lining membrane is thicker than elsewhere. 

1 ResearcJies on the Conduct of the Human Uterus after Delivery. 



THE PUERPERAL STATE AND ITS MANAGEMENT. 



551 



Contraction of the Vagina, etc. — The vagina soon contracts, and by 
the time the puerperal month is over it has returned to its normal 
dimensions, but after childbearing it always remains more lax and less 
rugose than in nulliparae. The vulva, at first very lax and much dis- 
tended, soon regains its former state. The abdominal parietes remain 



Fig. 192. 




Section of a Uterine Sinus from a Placental Site Nine Weeks after Delivery. (After Williams.) 

loose and flabby for a considerable time, and the white streaks produced 
by the distension of the cutis very generally become permanent I n some 
women, especially when proper support by bandaging has no1 been given, 
the abdomen remains permanently loose and pendulous. 

The Lochial Discharge. — From the time of delivery up i<> about 
three weeks afterward a discharge escapes from the interior of the ute- 
rus known as the lochia. At first this consists almosl entirely of pure 
blood, mixed with a variable amount of coagula. [f efficient uterine 
contraction has not been secured after the expulsion of the placenta, 
coagula of considerable size are frequently expelled with the lochia for 
one or two days after delivery. In three <>r four days the distinctly 
bloody character of the lochia is altered. They have a reddish w 
appearance, and are known as the lochia rubra or cruenh 1 1 lin-- 

to the researches of Wertheimer, 1 they are at this time composed chiefly 
of blood-corpuscles, mixed with epithelium ,-< , .-il<^ i mucous corpu 
and the debris of the decidua. The change in the appearance of the 
discharge progresses gradually, and about the seventh or eighth da) it 
has no longer a red color, but is ;i pale-greenish Quid with :i peculiar 
sickening and disagreeable odor, and is familiarly described as the " 

1 Virchoria Arch., L861. 



552 THE PUERPERAL STATE. 

waters." It now contains a small quantity of blood-corpuscles, which 
lessen in amount from day to day, but a considerable number of pus- 
corpuscles, which remain the principal constituent of the discharge until 
it ceases. Besides these, epithelial scales, fatty granules, and crystals of 
cholesterin are observed. Occasionally a small infusorium, which has 
been named the " Trichomena vaginalis/ 7 has been detected, but it is not 
of constant occurrence. 

Variation in its Amount and Duration. — The amount of the lochia 
varies much, and in some women it is habitually more abundant than in 
others. Under ordinary circumstances it is very scanty after the first 
fortnight, but occasionally it continues somewhat abundant for a month 
or more without any bad results. It is apt again to become of a red 
color and to increase in quantity in consequence of any slight excitement 
or disturbance. If this red discharge continues for any undue length 
of time, there is reason to suspect some abnormality, and it may not 
unfrequently be traced to slight lacerations about the cervix which have 
not healed properly. This result may also follow premature exertion, 
interfering with the proper involution of the uterus ; and the patient 
should certainly not be allowed to move about as long as much colored 
discharge is going on. 

Occasional Fetor of the Discharge. — Occasionally the lochia have an 
intensely fetid odor. This must always give rise to some anxiety, since 
it often indicates the retention and putrefaction of coagula and involves 
the risk of septic absorption. It is not very rare, however, to observe a 
most disagreeable odor persist in the lochia without any bad results. 
The fetor always deserves careful attention, and an endeavor should be 
made to obviate it by directing the nurse to syringe out the vagina freely 
night and morning with Condy's fluid and water, while, if it be associ- 
ated with quickened pulse and elevated temperature, other measures, to 
be subsequently described, will be necessary. 

The After- Pains. — The after-pains, which many childbearing women 
dread even more than the labor-pains, are irregular contractions occur- 
ring for a varying time after delivery, and resulting from the efforts of 
the uterus to expel coagula which have formed in its interior. If, there- 
fore, special care be taken to secure complete and permanent contraction 
after labor, they rarely occur, or to a very slight extent. Their depend- 
ence on uterine inertia is evidenced by the common observation that they 
are seldom met with in primiparse, in whom uterine contraction may be 
supposed to be more efficient, and are more frequent in women who have 
borne many children. They are a preventable complication, and one 
which need not give rise to any anxiety : they are, indeed, rather salu- 
tary than the reverse, for if coagula be retained in utero, the sooner they 
are expelled the better. The after-pains generally begin a few hours 
after delivery, and continue in bad cases for three or four days, but 
seldom longer. They are generally increased when the mammae are irri- 
tated by suction. When at their height they are often relieved by the 
expulsion of the coagula, In some severe cases they are apparently 
neuralgic in character, and do not seem to depend on the retention of 
coagula. They may be readily distinguished from pains due to more 
serious causes by feeling the enlarged uterus harden under their influ- 



THE PUERPERAL STATE AND ITS MANAGEMENT. 553 

ence, by the uterus not being tender on pressure, and by the absence of 
any constitutional symptoms. 

Management of Women after Delivery. — The management of women 
after childbirth has varied much at different times according to fashion 
or theory. The dread of inflammation long influenced the professional 
mind, and caused the adoption of a strictly antiphlogistic diet, which led 
to a tardy convalescence. The recognition of the essentially physiologi- 
cal character of labor has resulted in more sound views, with manifest 
advantage to our patients. The main facts to bear in mind with regard 
to the puerperal woman are — her nervous susceptibility, which n« 
tates quiet and absence of all excitement; the importance of favoring 
involution by prolonged rest ; and the risk of septicaemia, which calls for 
perfect cleanliness and attention to hygienic precautions. 

The Administration of Opiates is generally Unadvisable. — As soon as 
we are satisfied that the uterus is perfectly contracted and that all risk 
of hemorrhage is over, the patient should be left to sleep. Many prac- 
titioners administer an opiate, but, as a matter of routine, this is cer- 
tainly not good practice, since it checks the contractions of the uterus 
and often produces unpleasant effects. Still, if the labor have been long 
and tedious and the patient be much exhausted, 15 or 20 drops of l>at- 
tley's solution may be administered with advantage. 

Attention to the State of the Pulse, Bladder, and Uterus. — Within a 
few hours the patient should be seen, and at the first visit particular 
attention should be paid to the state of the pulse, the uterus, and the 
bladder. The pulse during the wdiole period of convalescence should 
be carefully watched, and if it be at all elevated the temperature should 
at once be taken. If the pulse and temperature remain normal, we may 
be satisfied that things are going on well; but if the one he quickened 
and the other elevated, some disturbance or complication may be appre- 
hended. The abdomen should be felt to see that the uterus is not 
unduly distended and that there is no tenderness. Alter the first day 
or two this is no longer necessary. 

Treatment of Retention of Urine. — Sometimes the patient cannot at 
first void the urine, and the application of a hot sponge over the pubes 
may enable her to do so. If the retention of urine be due t«> temporary 
paralysis of the bladder, three or four 20-minim doses of the liquid 
extract of ergot, at intervals of half an hour, may prove successful. 
Many hours should not be allowed to elapse without relieving the 
patient by the catheter, since prolonged retention is only likely l<» make 
matters worse. Subsequently, it may he necessary to empty the bladder 
night and morning until the patient regain her |><>\\er over ii or until 
the swelling of the urethra subside-, and this will generally !»' the case 
in a few days. Occasionally the bladder becomes largely distended, and 
is relieved to some degree by dribbling of urine from the urethra, Such 
a state of things may deceive the patient and nurse, Wd may produce 
serious consequences by causing cystitis. Attention t<> the condition 
of the abdomen will prevent the practitioner from being deceived, 
for in addition to some constitutional disturbance a large, under, 
and fluctuating swelling will l»c found in the hypogastric region, dis- 
tinct from the uterus, which it displaces I ie or other side. Hie 



554 THE PUERPERAL STATE. 

catheter will at once prove that this is produced by distension of the 
bladder. 

Treatment of Severe After-Pains. — If the after-pains be very severe 
an opiate may be administered, or if the lochia be not over-abundant a 
linseed-meal poultice sprinkled with laudanum or with the chloroform 
and belladonna liniment may be applied. If proper care have been 
taken to induce uterine contraction, they will seldom be sufficiently 
severe to require treatment. In America quinine, in doses of 10 grains 
twice daily, has been strongly recommended, especially when opiates fail 
and when the pains are neuralgic in character ; and I have found this 
remedy answer extremely well. The quinine is best given in solution 
with 10 or 15 minims of hydrobromic acid, which materially lessens the 
unpleasant head symptoms often accompanying the administration of 
such large doses. 

Diet and Regimen. — The diet of the puerperal patient claims careful 
attention, the more so as old prejudices in this respect are as yet far from 
exploded, and as it is by no means rare to find mothers and nurses who 
still cling tenaciously to the idea that it is essential to prescribe a low 
regimen for many days after labor. The erroneousness of this plan is 
now so thoroughly recognized that it is hardly necessary to argue the 
point. There is, however, a tendency in some to err in the opposite 
direction, which leads them to insist on the patient's consuming solid 
food too soon after delivery, before she has regained her appetite, thereby 
producing nausea and intestinal derangement. Our best guide in this 
matter is the feelings of the patient herself. If, as is often the case, she 
be disinclined to eat, there is no reason why she should be urged to do 
so. A good cup of beef-tea, some bread and milk, or an egg beat up 
with milk may generally be given with advantage shortly after delivery, 
and many patients are not inclined to take more for the first day or so. 
If the patient be hungry, there is no reason why she should not have 
some more solid but easily-digested food, such as white fish, chicken, or 
sweetbread ; and after a day or two she may resume her ordinary diet, 
bearing in mind that, being confined to bed, she cannot with advantage 
consume the same amount of solid food as when she is up and about. 
Dr. Oldham, in his presidential address to the Obstetrical Society, 1 has 
some apposite remarks on this point which are worthy of quotation : 
" A puerperal month under the guidance of a monthly nurse is easily 
drawn out, and it is w T ell if a love of the comforts of illness and the per- 
suasion of being delicate, which are the infirmities of many women, do 
not induce a feeble life which long survives after the occasion of it is 
forgotten. I know no reason why, if a woman is confined early in the 
morning, she should not have her breakfast of tea and toast at nine, her 
luncheon from some digestible meat at one, her cup of tea at five, her 
dinner with chicken at seven, and her tea again at nine, or the equiva- 
lent, according to the variation of her habits of living. Of course, there 
is the common-sense selection of articles of food, guarding against excess 
and avoiding stimulants. But gruel and slops and all intermediate 
feeding are to be avoided." No one who has seen both methods adopted 
can fail to have been struck with the more rapid and satisfactory conva- 

1 Obstet. Trans., vol. vi. 



THE PUERPERAL STATE AXD ITS MANAGEMENT. 555 

lescence which takes place when the patient's strength is not weakened 
by an unnecessarily low diet. Stimulants, as a rule, are not required, 
but if the patient be weakly and exhausted, or if she be accustomed to 
their use, there can be no reasonable objection to their judicious admin- 
istration. [As a rule, in the United States puerperal women have not 
been accustomed to the use of stimulants, and such are not advisable 
during their convalescence. The old system of starvation for three days 
has been done away with, but the opposite is also to be avoided. I 
believe in a spare diet for the robust and in feeding up the delicate. 
Where much blood has been lost I have found great benefit from the use 
of essence of beef, given in severe cases quite largely. As a rule, that 
made from three pounds of beef is to be given daily for two weeks, but 
I have used in a very extreme case as high as eleven pounds. The 
removal of the anaemic pallor is sometimes very decided within fifteen 
days under this diet. Of course the patient is to have a regular diet in 
addition to the essence of beef. — Ed.] 

Attention to Cleanliness, etc. — Immediately after delivery a warm 
napkin is applied to the vulva, and after the patient has rested a little 
the nurse removes the soiled linen from the bed and washes the external 
genitals. It is impossible to pay too much attention during the subse- 
quent progress of the case to the maintenance of perfect cleanliness. 
Perfectly antiseptic midwifery is no doubt an impossibility, but a near 
approach to it may be made, and the greater the care taken the more 
certainly will the safety of the patient be ensured. 1 It will be a wise 
precaution to advise the nurse never to touch the genitals lor the first 
few days unless her hands have been moistened in a i-ifl-20 solution of 
carbolic acid or a l-in-1000 solution of perchloride of mercury, or lubri- 
cated with carbolized oil. The linen should be frequently changed, and 

' The following rules I have for the past year or two distributed to the monthly 
nurses attending my own patients, with the result, I believe, of a marked improvement 
in their comfort and a more generally satisfactory convalescence : 

Antiseptic Rules for Monthly Nubses. 

1. Two hottles are supplied to each patient. One contains a mixture of phenol <>r 
pure carbolic acid, of the strength of one part to twenty of water (called the l-in-20 
solution), the other carbolized oil (l-in-8). 

2. A small basin containing the l-in-20 solution must always stand by the bedside 
of the patient, and the nurse must thoroughly rinse her hands in ii every time she 
touches the patient in tin; neighborhood of the genital organs for washing or any other 
purpose whatsoever, before; or during labor and for a week after delivery. 

3. All sponges, vaginal and rectal pipes, catheters, etc. musl be dipped in the l-in-20 

solution before being used. The: surfaces of slippers, bedpans, etc should alflO be 

sponged with it. 

4. Vaginal pipes, enema-tubes, catheters, etc. should besmeared with the carbolized 

oil before use. 

5. Unless express directions are given to the contrary, the vagina should ; 

twice daily after delivery with the L-in-20 solution, with an equal quantity of hoi water 
added to it. Occasionally the patienl finds that this smarts a little, in which ct 
quantity of warm water may be Blightly increased. 

6. All water used for washing should have sufficient Condy*s Quid dropped into it to 
give it a pah; pink color. 

7. All soiled linen, diapers, etc. should be immediately removed from the bedroom. 
N. B. — These rules are for the purpose of protecting the patienl from the risk arising 

from accidental contamination or the hands, sponges, etc h is therefore hoped thai 
they will be faithfully and minutely adhered to. 



556 THE PUERPERAL STATE. 

all dirty linen and discharges immediately removed from the apartment. 
The vulva should be washed daily with Condy's fluid and water, and 
the patient will derive great comfort from having the vagina syringed 
gently out once a day with the same solution. The remarkable diminu- 
tion of mortality which has followed such antiseptic precautions in cer- 
tain lying-in hospitals in Germany well shows the importance of these 
measures. The room should be kept tolerably cool and fresh air freely 
admitted. 

Action of the Boivels. — It is customary on the morning of the second 
or third day to secure an action of the bowels ; and there is no better 
way of doing this than by a large enema of soap and water. If the 
patient object to this and the bowels have not acted, some mild aperient 
may be administered, such as a small dose of castor oil, a few grains of 
colocynth and henbane pill, or the popular French aperient the " Tamar 
Indien." 

Lactation. — The management of suckling and of the breasts forms an 
important part of the duties of the monthly nurse which the practitioner 
should himself superintend. This will be more conveniently discussed 
under the head of Lactation. 

Importance of Prolonged Best. — The most important part of the man- 
agement of the puerperal state is the securing to the patient prolonged 
rest in the horizontal position, in order to favor proper involution of the 
uterus. For the first few days she should be kept as quiet and still as 
possible, not receiving the visits of any but her nearest relatives, thus 
avoiding all chance of undue excitement. It is customary among the 
better classes for the patient to remain in bed for eight or ten days ; but, 
provided she be doing well, there can be no objection to her lying on the 
outside of the bed or slipping on to a sofa somewhat sooner. After ten 
days or a fortnight she may be permitted to sit on a chair for a little ; 
but I am convinced that the longer she can be persuaded to retain the 
recumbent position, the more complete and satisfactory will be the prog- 
ress of involution ; and she should not be allowed to walk about until 
the third week, about which time she may also be permitted to take a 
drive. If it be borne in mind that it takes from six weeks to two 
months for the uterus to regain its natural size, the reason for prolonged 
rest will be obvious. The judicious practitioner, however, while insist- 
ing on this point, will take measures at the same time not to allow the 
patient to lapse into the habits of an invalid or to give the necessary 
rest the semblance of disease. 

Subsequent Treatment. — Toward the termination of the puerperal 
month some slight tonic, such as small doses of quinine with phos- 
phoric acid, may be often given with advantage, especially if convales- 
cence be tardy. Nothing is so beneficial in restoring the patient to her 
usual health as change of air, and in the upper classes a short visit to 
the seaside may generally be recommended, with the certainty of much 
benefit. 



MANAGEMENT OF THE IX FAST, LACTATION, ETC. 557 



CHAPTER II. 

MANAGEMENT OF THE INFANT, LACTATION, ETC. 

Commencement of Respiration. — Almost immediately after its expul- 
sion a healthy child cries aloud, thereby showing that respiration is 
established; and this may be taken as a signal of its safety. The first 
respiratory movements are excited partially by reflex action resulting 
from the contact of the cold external air with the cutaneous nerves, and 
partly by the direct irritation of the medulla oblongata in consequence 
of the circulation through it of blood no longer oxygenated in the 
placenta. 

Apparent Death of the New-born Child. — Xot infrequently the child 
is born in an apparently lifeless state. This is especially likely to be 
the case when the second stage of labor has been unduly prolonged, so 
that the head has been subjected to long-continued pressure. The utero- 
placental circulation is also apt to be injuriously interfered with before 
the birth of the child when a tardy labor has produced tonic contraction 
of the uterus and consequent closure of the uterine sinuses, or, more 
rarely, from such causes as the injudicious administration of ergot, pre- 
mature separation of the placenta, or compression of the umbilical cord. 
In any of these cases it is probable that the arrest of the utero-placentaJ 
circulation induces attempts at inspiration which are necessarily fruit- 
less, since air cannot reach the lungs, and the foetus may die asphyx- 
iated; the existence of the respiratory movement being proved on post- 
mortem examination by the presence in the lungs of liquor amnii, mucus, 
and meconium, and by the extravasation of blood from the rupture of 
their engorged vessels. 

Appearance of the Child in such Cases. — In mosl cases, when the 
child is born in a state of apparent asphyxia, its face is swollen and of 
a dark livid color. It not infrequently makes one or two feeble and 
gasping efforts at respiration, without any definite cry ; on auscultation 
the heart maybe heard to beat weakly and slowly. Under such circum- 
stances there is a fair hope of its recovery. In other cases the child, instead 
of being turgid and livid in the face, is pale, with flaccid limbs, and do 
appreciable cardiac action ; then the prognosis is much more unfavorable 

Treatment of Apparent Death. — No time should be l<»~t in endeavor- 
ing to excite respiration; and at firsi tlii- must be done by applying 
suitable stimulants to the cutaneous nerves in the hope of exciting reflex 
action. The cord should be at once tied and the child removed Prom 
the mother, for the final uterine contractions have bo completely arrested 
the utero-placental circulation as to render it no longer of any value. 
If the face be very livid, a few drops of blood may with advantage be 
allowed to flow from the cord before it is tied, with the view of relieving 
the embarra»ed circulation. Very often some slighl stimulus, such ;i- 
one or two sharp slaps on the thorax or rapidly rubbing tli<' bod} with 



558 THE PUERPERAL STATE. 

i 

brandy poured into the palms of the hands, will suffice to induce respira- 
tion. Failing this, nothing acts so well as the sudden and instantaneous 
application of heat and cold. For this purpose extremely hot water is 
placed in one basin, and quite cold water in another. Taking the child 
by the shoulders and legs, it should be dipped for a single moment into 
the hot water and then into the cold ; and these alternate applications 
may be repeated once or twice as occasion requires. The effect of this 
measure is often very marked, and I have frequently seen it succeed 
when prolonged efforts at artificial respiration had been made in vain. 

Artificial Respiration. — If these means fail an endeavor must be at 
once made to carry on respiration artificially. The Sylvester method is, 
on the whole, that which is most easily applied, and, on account of the 
compressibility of the thorax, it is peculiarly suitable for infants. The 
child being laid on its back with the shoulders slightly elevated, the 
elbows are grasped by the operator and alternately raised above the head 
and slowly depressed against the sides of the thorax, so as to produce the 
effect of inspiration and expiration. If this do not succeed, the Marshall 
Hall method may be substituted, and one or more of the plans of excit- 
ing reflex action through the cutaneous nerves may be alternated with it. 

Insufflation of the Lungs. — Other means of exciting respiration have 
been recommended. One of them, much used abroad, is the artificial 
insufflation of the lungs by means of a flexible catheter guided into 
the glottis. It is not difficult to pass the end of a catheter into the 
glottis, using the little finger as a guide ; and, once in position, it may 
be used to blow air gently into the lungs, which is expelled by compres- 
sion on the thorax, the insufflation being repeated at short intervals of 
about ten seconds. One advantage of this plan is that it allows the 
liquor amnii and other fluids, which may have been drawn into the 
lungs in the premature efforts at respiration before birth, to be sucked 
up into the catheter, and so removed from the lungs. The same effect 
may be produced, but less perfectly, by placing the hand over the nos- 
trils of the child, blowing into its mouth, and immediately afterward 
compressing the thorax. [ x ] One of these two methods should certainly 
be tried if all other means have failed. Faradization along the course 
of the phrenic nerves is a promising means of inducing respiration which 
should be used if the proper apparatus can be procured. Encouragement 
to persevere in our endeavors to resuscitate the child may be derived 
from the numerous authenticated instances of success after the lapse of 
a considerable time, even of an hour or more. As long as the cardiac 
pulsations continue, however feebly, there is no reason to despair. 

Washing and Dressing of the Child. — When the child cries lustily 
from the first, it is customary for the nurse to wash and dress it as soon 
as her immediate attendance on the mother is no longer required. For 
this purpose it is placed in a bath of warm water and carefully soaped 
and sponged from head to foot. With the view of facilitating the 
removal of the unctuous material with which it is covered, it is usual 
to anoint it with cold cream or olive oil, which is washed off in the 

\} The oesophagus must be closed by placing the thumb and fingers on either side of 
the larynx and pressing it back, or you will inflate the stomach instead of the lungs. — 
Ed.] 



MANAGEMENT OF THE INFANT, LACTATION, E 

bath. Nurses are apt to use undue roughness in endeavoring to remove 
every particle of the vernix caseosa, small portions of which are often 
firmly adherent. This mistake should be avoided, as these particles will 
soon dry up and become spontaneously detached. The cord is generally 
wrapped in a small piece of charred linen, which is supposed to have 
some slight antiseptic property, and this is renewed from day to day 
until the cord has withered and separated. This generally occur- within 
a week, and a small pad of soft linen is then placed over the umbilicus, 
and supported by a flannel belly-band placed round the abdomen, which 
should not be too tight, for fear of embarrassing the respiration. By 
this means the tendency to umbilical hernia is prevented. [As the ver- 
nix caseosa is readily miscible with pure lard, and can be easily removed 
by its means, it has become the practice with many obstetricians in the 
United States to order the infant to be well anointed, and then wiped 
from head to foot with soft rags, until all the vernix disappear.-, and the 
skin retains a slight oily trace, not enough to soil the clothing. By this 
means water is avoided, and with it much of the risk of taking cold, and 
the skin is left less sensitive after the sudden change which it Is made to 
endure at birth than when subjected to hot water and soap. In the hot 
months water is preferable at the first dressing. — Ed.] 

Clothing, etc. — The clothing of the infant varies according to fashion 
and the circumstances of the parents. The important points to bear 
in mind are that it should be warm (since newly-born children are ex- 
tremely susceptible to cold), and at the same time light and sufficiently 
loose to allow free play to the limbs and thorax. All tight bandaging 
and sw T addling, such as is so common in some pails of the Continent, 
should be avoided, and the clothes should be fastened by strings or by 
sewing, and no pins used. At the present day it i- customary not to use 
caps, so that the head may be kept cool. The utmost possible attention 
should be paid to cleanliness, and the child should be regularly bathed 
in tepid water — at first once daily, and after the fust few week- both 
night and morning. After drying, the flexures of the thighs and arms 
and the nates should be dusted with violet powder or fuller'- earth, to 
prevent chafing of the skin. The excrements should be received in nap 
kins wrapped round the hips, and great care is required to change the 
napkins as often as they arc; wet or soiled, otherwise troublesome irrita- 
tion will arise. A neglect of this precaution and the washing of the 
napkins with coarse soap or soda are among the principal causes oi the 
eruptions and excoriations so common in badly cared-for children. \\ hen 
washed and dressed the child may be placed in its cradle and 001 
with soft blankets or an eider-down (jiiilt. 

Application of the Child to the Breast. — As soon a- the mother has 
rested a little it is advisable to place the child to the breast This is 
useful to the mother by favoring uterine contraction. Even now there 
is in the breasts a variable quantity of the peculiar fluid known ., 
lo8trum. This is a viscid yellowish secretion, diflferenl in appearance 
from the thin bluish milk which is subsequently formed. Examined 
under the microscope, it is found to contain some milk-globules and a 
number of large granular and small fafc-corpuscles. It baa a purgative 
property, and soon produces, with less irritation than any oi the laxa- 



560 THE PUERPERAL STATE. 

tives so generally used, a discharge of the meconium with which the 
bowels are loaded. Hence the accoucheur should prohibit the common 
practice of administering castor oil or other aperient within the first few 
days after birth, although there can be no objection to it in special cases 
if the bowels appear to act inefficiently and with difficulty. 

Over-frequent Suckling should be Avoided. — For the first few days, 
and until the secretion of milk is thoroughly established, the child 
should be put to the breast at long intervals only. Constant attempts 
at sucking an empty breast lead to nothing but disappointment, both to 
the mother and child, and, by unduly irritating the mammse, sometimes 
to positive harm. Therefore, for the first day or two it is sufficient if the 
child be applied to the breast twice, or at most three times, in the twenty- 
four hours. Nor is it necessary to be apprehensive, as many mothers 
naturally are, that the child will suffer from want of food. A few spoon- 
fuls of milk and water being given from time to time, the child may 
generally wait without injury until the milk is secreted. This is gen- 
erally about the third day, when the secretion is found to be a whitish 
fluid, more watery in appearance than cow's milk, and showing under 
the microscope an abundance of minute spherical globules, refracting 
light strongly, which are abundant in proportion to the quality of the 
milk. A certain number of granular corpuscles may also be observed 
shortly after the birth of the child, but after the first month these should 
have almost altogether disappeared. The reaction of human milk is 
decidedly alkaline, and the taste much sweeter than that of cow's milk. 

Importance of 'Nursing when Practicable. — The importance to the 
mother of nursing her own child whenever her health permits, on 
account of the favorable influence of lactation in promoting a proper 
involution of the uterus, has already been insisted on. Unless there be 
some positive contraindication, such as a marked strumous cachexia, an 
hereditary phthisical tendency, or great general debility, it is the duty 
of the accoucheur to urge the mother to attempt lactation, even if it be 
not carried on more than a month or two. It is, however, the fact that 
in the upper classes of society a large number of patients are unable to 
nurse, even though willing and anxious to do so. In some there is 
hardly any lacteal secretion at all ; in others there is at first an over- 
abundance of watery and innutritious milk, which floods the breasts and 
soon dies away altogether. 

When the Mother cannot Nurse, a Wet-nurse should be Procured. — 
Whenever the mother cannot or will not nurse the question will arise as 
to the method of bringing up the child. From many causes there is an 
increasing tendency to resort to bottle-feeding, instead of procuring the 
services of a wet-nurse, even when the question of expense does not 
come into consideration. No long experience is required to prove that 
hand-feeding is a bad and imperfect substitute for nature's mode, and 
one which the practitioner should discourage Avhenever it lies in his 
power to do so. It is true that in many cases bottle-fed children do 
well, but there is good reason to believe that, even when apparently 
most successful, the children are not so strong in after-life as they would 
have been had they been brought up at the breast. When, in addition, 
it is borne in mind how much of the success of hand-feeding depends 



MANAGEMENT OF THE INFANT, LACTATION, ETC 561 

on intelligent care on the part of the nurse, what evils are apt to accrue 
from the injurious selection of the food and from ignorance of the com- 
monest laws of dietetics, there is abundant reason for urging the substi- 
tution of a wet-nurse whenever the mother is unable to undertake the 
suckling of her child. It must be admitted that good hand-feeding is 
better than bad wet-nursing, and the success of the latter hinges on the 
proper selection of a wet-nurse. As this falls within the duties of the 
practitioner, it will be well to point out the qualities which should be 
sought for in a wet-nurse, before proceeding to discuss the mode of rear- 
ing the child at the breast. 

Selection of a Wet-nurse. — In selecting a wet-nurse we should endeavor 
to choose a strong, healthy woman, who should not be over o<> ? or 35 
years of age at the outside, since the quality of the milk deteriorates in 
women who are more advanced in life. For a similar reason a very 
young woman of 16 or 17 should be rejected. It is needle— to say that 
care must be taken to ascertain the absence of all traces of constitutional 
disease, especially marks of scrofula or enlarged cervical or inguinal 
glands, which may possibly be due to antecedent syphilitic taint. If 
the nurse be of good muscular development, healthy-looking, with a 
clear complexion, and sound teeth (indicating a generally good state of 
health), the color of the hair and eyes is of secondary importance. It is 
commonly stated that brunettes make better nurses than blonde-, but 
this is by no means necessarily the case, and, provided all the other 
points be favorable, fairness of skin and hair need be no bar to the selec- 
tion of a nurse. The breasts should be pear-shaped, rather firm, a- 
indicating an abundance of gland-tissue, and with the superficial veins 
well marked. Large, flabby breasts owe much of their size to an undue 
deposit of flit, and are generally unfavorable. The nipple should be 
prominent, not too large, and free from cracks and erosions, which, if 
existing, might lead to subsequent difficulties in nursing. On pressing 
the breast the milk should flow from it easily in a number of small jet-, 
and some of it should be preserved for examination. It should be of a 
bluish-white color, and when placed under the microscope the field 
should be covered with an abundance of milk-corpuscles and tin- large 
granular corpuscles of the colostrum should have entirely disappeared. 
If the latter be observed in any quantity in a woman who ha- been '■on- 
fined five or six week-, the inference is thai the milk is inferior in quality. 
It is not often that the practitioner has an opportunity of inquiring into 
the moral qualities of the nurse, although much valuable information 
might be derived from a knowledge or her previous character. An 
irascible, excitable, or highly-nervous woman will certainly make a bad 
nurse, and the most trivial causes might afterward interfere with the 
quality of her milk. Particular attention should be paid to the 01 
own child, since it- condition affords the best criterion of the quality of 
her milk. It should be plump, well-nourished, and free from all blem- 
ishes. W it be at all thin and wizened, especially if there be any snuf- 
fling at the nose, or should any eruption exist affording the slightest 
pieion of a syphilitic taint, the nurse should be unhesitatingly rejected 

Management of Suckling. — The management of suckling i- much the 
same whether the child i- nursed by the mother or by a wret-nurse. A- 

36 



562 THE PUERPERAL STATE. 

soon as the supply of milk is sufficiently established, the child must be 
put to the breast at short intervals — at first of about two hours, and in 
about a month or six weeks of three hours. From the first few days it 
is a matter of the greatest importance, both to the mother and child, to 
acquire regular habits in this respect. If the mother get into the way 
of allowing the infant to take the breast whenever it cries as a means 
of keeping it quiet, her own health must soon suffer, to say nothing of 
the discomfort of being incessantly tied to the child's side ; while the 
child itself has not sufficient rest to digest its food, and very shortly diar- 
rhoea or other symptoms of dyspepsia are pretty sure to follow. After 
a month or two the infant should be trained to require the breast less 
often at night, so as to enable the mother to have an undisturbed sleep 
of six or seven hours. For this purpose she should arrange the times 
of nursing so as to give the breast just before she goes to bed, and not 
again until the early morning. If the child should require food in the 
interval, a little milk and water from the bottle may be advantageously 
given. 

Diet of Nursing Women. — The diet of the nursing Avoman should be 
arranged on ordinary principles of hygiene. It should be abundant, 
simple, and nutritious, but all rich and stimulating articles of food 
should be avoided. A common error in the diet of wet-nurses is over- 
feeding, which constantly leads to deterioration of the milk. Many of* 
these women before entering on their functions have been living on the 
simplest and even sparest diet, and not uncommonly, in the better class 
of houses, they are suddenly given heavy meat meals three and even 
four times a day, and often three or four glasses of stout. It is hardly 
a matter of astonishment that under such circumstances their milk should 
be found to disagree. For a nursing woman in good health two good 
meat meals a day, with two glasses of beer or porter, and as much milk 
and bread and butter as she likes to take in the intervals, should be 
amply sufficient. Plenty of moderate exercise should be taken, and the 
more nurse and child are out in the open air, provided the weather be 
reasonably fine, the better it is for both. [As a rule, American wet- 
nurses have been much better fed than those here described, and have 
not been in the habit of using malt drinks. A healthy woman will 
usually nurse well on her ordinary diet, which should be largely farina- 
ceous. If she can drink milk, there is nothing equal to it in furnishing 
a lacteal supply. — Ed.] 

Signs of Successful Lactation. — Carried on methodically in this man- 
ner, wet-nursing should give but little trouble. In the intervals between 
its meals the child sleeps most of its time, and wakes with regularity to 
feed ; but if the child be wakeful and restless, cry after feeding, have 
disordered bowels, and, above all, if it do not gain week by week in 
weight (a point which should be from time to time ascertained by the 
scales), we may conclude that there is either some grave defect in the 
management of suckling or that the milk is not agreeing. Should this 
unsatisfactory progress continue in spite of our endeavors to remedy it, 
there is no resource left but the alteration of the diet, either by chang- 
ing the nurse or by bringing up the child by hand. The former should 
be preferred whenever it is practicable, and in the upper ranks of life it 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 563 

is by no means rare to have to change the wet-nurse two or three times 
before one is met with whose milk agrees perfectly. If the child have 
reached six or seven months of age, it may be preferable to wean it alto- 
gether, especially if the mother have nursed it, as hand-feeding is much 
less objectionable if the infant have had the breast for even a few 
months. 

Period of Weaning. — As a rule, weaning should not be attempted 
until dentition is fairly established, that being the sign that nature has 
prepared the child for an alteration of food ; and it is better that the 
main portion of the diet should be breast milk until at least six or 3even 
teeth have appeared. This is a safer guide than any arbitrary rule taken 
from the age of the child, since the commencement of dentition varies 
much in diiferent cases. About the sixth or seventh month it is a good 
plan to commence the use of some suitable artificial food once a day, so 
as to relieve the strain on the mother or nurse and prepare the child for 
weaning, which should always be a very gradual process. In this way 
a meal of rusks of the entire wheat flour, or of beef- or chicken-tea with 
bread-crumb in it, may be given with advantage ; and as the period for 
weaning arrives a second meal may be added, and so eventually the 
child may be weaned without distress to itself or trouble to the nurse. 

The Disorders of Lactation. — The disorders of lactation are numer- 
ous, and, as they frequently come under the notice of the practitioner, it 
is necessary to allude to some of the most common and important. 

Means of Arresting the Secretion of Milk. — The advice of the accouch- 
eur is often required in cases in which it has been determined that the 
patient is not to nurse, when we desire to get rid of the milk as soon as 
possible, or when, at the time of weaning, the same object is sought. 
The extreme heat and the distension of the breasts in the former da— of 
cases often give rise to much distress. A smart saline aperient will aid 
in removing the milk, and for this purpose a double Seidlitz powder or 
frequent small doses of sulphate of magnesia act well, while, at the same 
time, the patient should be advised to take as small a quantity <>!* fluid 
as possible. Iodide of potassium in large doses of 20 <>r 25 grains, 
repeated twice or thrice, has a remarkable effect in arresting the secretion 
of milk. This observation was first empirically made by oTjserving that 
the secretion of milk was arrested when this dvwj; was administered i'm- 
some other cause; and 1 have frequently found it answer remarkably 
well. The distension of the breasts is best relieved by covering them 
with a layer of lint or cotton wool soaked in a spirit lotion or eau de 
Cologne and water, over which oiled sill< is placed, and by directing the 
nurse to rub them gently with warm oil whenever they gel hard and 
lumpy. Breast-pumps and similar contrivances only irritate the breasts, 
and do more harm than good. The local application of belladonna has 
been strongly recommended as a means \ni preventing lacteal secretion. 
As usually applied, in the form of belladonna plaster, it i- likely t.. 
prove hurtful, since the breast often enlarges after the plasters are 
applied, and the pressure of the unyielding leather on which they are 
spread produces intense suffering. A better way of using it i- by rub- 
bing down a drachm of the extract of belladonna with an ounce "I" 
glycerin and applying this on lint. In some cases ii answi i Ktremely 



564 THE PUERPERAL STATE. 

well, but it is very uncertain in its action, and frequently is quite 
useless. 

Defective Secretion of 31ilk. — A deficiency of milk in nursing mothers 
is a very common source of difficulty. In a wet-nurse this drawback is, 
of course, an indication for changing the nurse ; but to the mother the 
importance of nursing is so great that an endeavor must be made either 
to increase the flow of milk or to supplement it by other food. Unfor- 
tunately, little reliance can be placed on any of the so-called galacta- 
gogues. The only one Avhich in recent times has attracted attention is 
the leaves of the castor-oil plant, which, made into poultices and applied 
to the breast, are said to have a beneficial effect in increasing the flow of 
milk. More reliance must be placed in the sufficiency of nutritious 
food, especially such as contains phosphatic elements ; stewed eels, oys- 
ters, and other kinds of shellfish, and the Revalenta Arabica, are recom- 
mended by Dr. Routh, who has paid some attention to this point, 1 as 
peculiarly appropriate. If the amount of milk be decidedly deficient, 
the child should be less often applied to the breast, so as to allow milk 
to collect, and properly prepared cow's milk from a bottle should be 
given alternately with the breast. This mixed diet generally answers 
well, and is far preferable to pure hand-feeding. [There is no diet 
equivalent to milk for a nursing mother, where it agrees with her. This 
I have tested repeatedly in women who had failed entirely in former 
attempts to nurse their infants. One lady who had lost her milk three 
times at the end of a month, and had nursed two babies into starvation, 
was enabled to nurse her fourth while on a milk diet for eighteen months, 
and gained while doing so 19 pounds. Another gained 65 pounds while 
nursing, and her son was very large for his age. A third lost a child 
by hand-feeding, and nursed the next infant on a milk diet, at the same 
time becoming fatter than she had ever been. A decided advantage in 
the use of milk is, that it prevents the exhausted feeling so common with 
delicate nursing mothers. I have had a patient of 86 pounds weight use 
two quarts of milk a clay, and at the same time eat her usual measure 
of food, which had always been of small amount. — Ed.] 

Depressed Nipples. — A not uncommon source of difficulty is a depressed 
condition of the nipples, which is generally produced by the constant 
pressure of the stays. The result is, that the child, unable to grasp the 
nipple and wearied with ineffectual efforts, may at last refuse the breast 
altogether. An endeavor should be made to elongate the nipple before 
putting it into the child's mouth, either by the fingers or by some form 
of breast-pump, which here finds a useful application. In the worst 
class of cases, when the nipple is permanently depressed, it may be 
necessary to let the child suck through a glass nipple shield to which is 
attached an india-rubber tube, similar to that of a sucking-bottle ; this 
it is generally well able to do. [In some instances this anatomical defect 
appears to be beyond remedy, unless a proposed surgical operation can 
be made effective. I have tried to prepare primiparse for several months 
before labor, and then failed as soon as the breasts filled with milk. In 
some cases there is absolutely no nipple, and as a shield is of no value 
in protection, the escaping milk produces an eczema over the waist and 

1 Routh on Infant -feeding. 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 565 

upper part of the abdomen. This condition I have seen associated with 
a most obstinate galactorrhea lasting several months. — Ed.] 

Fissures and Excoriations of the Nipples. — Fissures and excoriations 
of the nipples are common causes of suffering, in some cases leading to 
mammary abscess. Whenever the practitioner has the opportunity, he 
should advise his patient to prepare the nipple for nursing in the latter 
months of pregnancy; and this may best be done by daily bathing it 
with a spirituous or astringent lotion, such as eau de Cologne and water 
or a weak solution of tannin. After nursing has begun great care should 
be taken to wash and dry the nipple after the child has been applied to 
it, and as long as the mother is in the recumbent position she may, if 
the nipples be at all tender, use zinc nipple-shields with advantage when 
she is not nursing. In this way these troublesome complications may 
generally be prevented. The most common forms are either an abrasion 
on the surface of the nipple, which, if neglected, may form a small 
ulcer, or a crack at some part of the nipple, most generally at its base. 
In either case the suffering when the child is put to the breast is intense, 
sometimes indeed amounting to intolerable anguish, causing the mother 
to look forward with dread to the application of the child. Whenever 
such pain is complained of, the nipple should be carefully examined, 
since the fissure or sore is often so minute as to escape superficial examina- 
tion. The remedies recommended are very numerous and not always 
successful. Amongst those most commonly used are astringent applica- 
tions, such as tannin or weak solutions of nitrate of silver, or cauteriz- 
ing the edges of the fissure with solid nitrate of silver, or applying the 
flexible collodion of the Pharmacopoeia. Dr. Wilson of Glasgow speaks 
highly of a lotion composed of ten grains of nitrate of lead in an ounce 
of glycerin, which is to be applied after suckling, the nipple being care- 
fully washed before the child is again put to the breast. I have myself 
found nothing answer so well as a lotion composed of half an ounce of 
sulphurous acid, half an ounce of the glycerin of tannin, and an ounce 
of water, the beneficial effects of which are sometimes quite remarkable. 
Relief may occasionally be obtained by inducing the child to suck 
through a nipple-shield, especially when there is only an excoriation; 
but this will not always answer, on account of the extreme pain which 
it produces. 

Excessive Flow of Milk. — An excessive flow of milk, known as galao- 
tvrrhcea, often interferes with successful lactation. It is by no means 
rare in the first weeks after delivery for women of delicate constitution. 
who are really unfit to nurse, to be flooded with a superabundance of 
watery and innutritions milk, which soon produces disordered digestion 
in the child. Under such circumstances the only thing to be done is to 
give up an attempt which is injurious both to the mother and child. At 
a later stage the milk, secreted" in large quantities, is sufficient!} nourish- 
ing to the child, but the drain on the mother's constitution soon begins 
to tell on her. Palpitation, giddiness, emaciation, headache, loss of 
sleep, spots before the eves indicate the serioufl effects which are being 
produced and the absolute necessity of a1 once stopping lactation. 
Whenever, therefore, a nursing woman suffers from such symptoms, 
it is far better at once to remove the cause, otherwise m very - rious and 



566 THE PUERPERAL STATE. 

permanent deterioration of health might result. When, under such cir- 
cumstances, nursing is unwisely persevered in, most serious results may 
follow. Should any diathetic tendency exist, especially when there is a 
predisposition to phthisis, nothing is so likely to develop it as the debil- 
ity produced by excessive lactation. Certain diseases of the eye are then 
specially apt to occur, such as severe inflammation of the cornea, leading 
to opacity and even sloughing, and certain forms of choroiditis ; also 
impairment of accommodation due to defective power of the ciliary 
muscle. 1 

Mammary Abscess. — There is no more troublesome complication of 
lactation than the formation of abscess in the breast — an occurrence by 
no means rare, and which, if improperly treated, may, by long-continued 
suppuration and the formation of numerous sinuses in and about the 
breast, produce very serious effects on the general health. The causes 
of breast abscesses are numerous, and very trivial circumstances may 
occasionally set up inflammation, ending in suppuration. Thus it may 
follow exposure to cold, a blow or other injury to the breast, some tem- 
porary engorgement of the lacteal tubes, or even sudden or depressing 
mental emotions. The most frequent cause is irritation from fissures or 
erosions of the nipples, which must therefore always be regarded with 
suspicion, and cured as soon as possible. 

Signs and Symptoms. — The abscess may form in any part of the breast 
or in the areolar tissue below it ; in the latter case the inflammation very 
generally extends to the gland-structure. Abscess is usually ushered in 
by constitutional symptoms, varying in severity with the amount of the 
inflammation. Pyrexia is always present ; elevated temperature, rapid 
pulse, and much malaise and sense of feverishness, followed in many 
cases by distinct rigor when deep-seated suppuration is taking place. 
On examining the breast it will be found to be generally enlarged and 
very tender, while at the site of the abscess an indurated and painful 
swelling may be felt. If the inflammation be chiefly limited to the sub- 
glandular areolar tissue, there may be no localized swelling felt, but the 
whole breast will be acutely sensitive and the slightest movement will 
cause much pain. As the case progresses the abscess becomes more and 
more superficial, the skin covering it is red and glazed, and if left to itself 
it bursts. In the more serious cases it is by no means rare for multiple 
abscesses to form. These, opening one after the other, lead to the forma- 
tion of numerous fistulous tracts, by which the breast may become com- 
pletely riddled. Sloughing of portions of the gland-tissue may take 
place, and even considerable hemorrhage from the destruction of blood- 
vessels. The general health soon suffers to a marked degree, and, as 
the sinuses continue to suppurate for many successive months, it is by 
no means uncommon for the patient to be reduced to a state of profound 
and even dangerous debility. 

Treatment. — Much may be done by proper care to prevent the forma- 
tion of abscess, especially by removing engorgement of the lacteal ducts, 
when threatened, by gentle hand-friction in the manner already indi- 

1 See Foerster of Breslau in Graefe and Saemisch's Handbuch des Gesammten Augen- 
heilkunde, and Power on " The Diseases of the Eve in Connection with Pregnancy," 
Lancet, May 8, 1880, et seq. 



MANAGEMENT OF THE INFANT, LACTATION, ETC. 567 

cated. When the general symptoms and the local tenderness indicate 
that inflanimtion has commenced, we should at once endeavor to mod- 
erate it, in the hope that resolution may occur without the formation of 
pus. Here general principles must be attended to, especially giving the 
affected part as much rest as possible. Feverishness may be combated 
by gentle salines, minute doses of aconite, and large doses of quinine, 
while pain should be relieved by opiates. The patient should be strictly 
confined in bed, and the affected breast supported by a suspensory band- 
age. Warmth and moisture are the best means of relieving the local 
pain, either in the form of hot fomentations or of light poultices of lin- 
seed meal or bread and milk, and the breast may be smeared with 
extract of belladonna rubbed down with glycerin, or the belladonna 
liniment sprinkled over the surface of the poultices. The local appli- 
cation of ice in india-rubber bags has been highly extolled as a means 
of relieving the pain and tension, and is said to be much more effectual 
than heat and moisture. 1 Generally, the pain and irritation produced by 
putting the child to the breast are so great as to contraindicate nursing 
from the affected side altogether, and we must trust to relieving the 
tension by poultices, suckling being in the mean time carried on by the 
other breast alone. In favorable cases this is quite possible for a time, 
and it may be that, if the inflammation do not end in suppuration or if 
the abscess be small and localized, the affected breast is again able to 
resume its functions. Often this is not possible, and it may be advisable 
in severe cases to give up nursing altogether. 

Pus should be Removed as Soon as Possible. — The subsequent manage- 
ment of the case consists in the opening of the abscess as soon as the 
existence of pus is ascertained, either by fluctuation or, if the site of the 
abscess be deep seated, by the exploring-needle. It may be laid down 
as a principle that the sooner the pus is evacuated the better, and noth- 
ing is to be gained by waiting until it is superficial. On the contrary. 
such delay only leads to more extensive disorganization of tissue and the 
further spread of inflammation. 

Antiseptic Treatment of MamMary Abscess. — The method of opening 
the abscess is of primary importance. It has always been customary 
simply to open the abscess at its most dependent part, without using 
any precaution against the admission of air, and afterward to treat 
secondary abscesses in the same way. The results are well known t«« .ill 
practical accoucheurs, and the records of surgery fully show how many 
weeks or months generally elapse in bad cases before recovery is com- 
plete. The antiseptic treatment of mammary abscess, in the way first 
pointed out by Lister, affords results which are of the mosl remarkable 
and satisfactory kind, [nstead of being week- and months in healin . 
I believe that' the practitioner who fairly and minutely carries out Sir 
Joseph Lister's direction- may confidently look for complete closure of 
the abscess in a few days j and I know of nothing in tin- whole range 
of my professional experience thai has given me more satisfaction than 
the application of this method to abscesses of the breast The plan I 
first used is thai recommended by Lister in the Lcmod for L867, bul 
which is now superseded l>v his improved methods, which "i course will 
1 Carson, Amer. Jmim. of Ob*UL. Jan., 1881. 



568 THE PUERPERAL STATE. 

be used in preference by all who have made themselves familiar with 
the details of antiseptic surgery. The former, however, is easily within 
the reach of every one, and is so simple that no special skill or practice 
is required in its application, whereas the more perfected antiseptic ap- 
pliances will probably not be so readily obtained and are much more 
difficult to use. I therefore insert Sir Joseph Lister's original direc- 
tions, which he assures me are perfectly antiseptic, for the guidance of 
those who may not be able to obtain the more elaborate dressings : " A 
solution of one part of crystallized carbolic acid in four parts of boiled 
linseed oil having been prepared, a piece of rag from four to six inches 
square is dipped into the oily mixture and laid upon the skin where the 
incision is to be made. The lower edge of the rag being then raised 
while the upper edge is kept from slipping by an assistant, a common 
scalpel or bistoury dipped in the oil is plunged into the cavity of the 
abscess, and an opening about three-quarters of an inch in length is 
made ; and the instant the knife is withdrawn the rag is dropped upon 
the skin as an antiseptic curtain, beneath which the pus flows out into a 
vessel placed to receive it. The cavity of the abscess is firmly pressed, 
so as to force out all existing pus as nearly as may be (the old fear of 
doing mischief by rough treatment of the pyogenic membrane being 
quite ill-founded) ; and if there be much oozing of blood, or if there be 
considerable thickness of parts between the abscess and the surface, a 
piece of lint dipped in the antiseptic oil is introduced into the incision to 
check bleeding and prevent primary adhesion, which is otherwise very 
apt to occur. The introduction of the lint is effected as rapidly as may 
be, and under the protection of the antiseptic rag. Thus the evacuation 
of the original contents is accomplished with perfect security against the 
introduction of living germs. This, however, would be of no avail un- 
less an antiseptic dressing could be applied that would effectually prevent 
the decomposition of the stream of pus constantly flowing out beneath it. 
After numerous disappointments I have succeeded with the following, 
which may be relied upon as absolutely trustworthy : About six tea- 
spoonfuls of the above-mentioned solution of carbolic acid in linseed 
oil are mixed up with common whiting (carbonate of lime) to the con- 
sistence of a firm paste, which is, in fact, glazier's putty with the addi- 
tion of a little carbolic acid. This is spread upon a piece of common 
tin-foil about six inches square, so as to form a layer about a quarter of 
an inch thick. The tin-foil, thus spread with putty, is placed upon the 
skin so that the middle of it corresponds to the position of the incision, 
the antiseptic rag used in opening the abscess being removed the instant 
before. The tin is then fixed securely by adhesive plaster, the lowest 
edge being left free for the escape of the discharge into a folded towel 
placed over it and secured by a bandage. The dressing is changed, as a 
general rule, once in twenty-four hours, but if the abscess be a very 
large one it is prudent to see the patient twelve hours after it has been 
opened, when, if the towel should be much stained with discharge, the 
dressing should be changed, to avoid subjecting its antiseptic virtues to 
too severe a test. But after the first twenty-four hours a single daily 
dressing is sufficient. The changing of the dressing must be method- 
ically done, as follows : A second similar piece of tin-foil having been 



MANAGEMENT OF THE IXFAXT, LACTATION, ETC. 569 

spread with the putty, a piece of rag is dipped in the oily solution and 
placed on the incision the moment the first tin is removed. This guards 
against the possibility of mischief occurring during the cleansing of the 
skin with a dry cloth and pressing out any discharge which may exist 
in the cavity. If a plug of lint was introduced when the abscess un- 
opened, it is removed under cover of the antiseptic rag, which is taken 
off at the moment when the new tin is to be applied. The same process 
is continued daily until the sinus closes." 

Treatment of Long-continued Suppuration and Fever. — If the case 
come under our care when the abscess has been long discharging or 
when sinuses have formed, the treatment is directed mainly to procuring 
a cessation of suppuration and closure of the sinuses. For this purpose 
methodical strapping of the breast with adhesive plaster, so as to afford 
steady support and compress the composing pyogenic surfaces, will give 
the best results. It may be necessary to lay open some of the sinuses, 
or to inject tinct. iodi or other stimulating lotions so as to moderate the 
discharge, the subsequent surgical treatment varying according to the 
requirements of each case. In such neglected cases Billroth recom- 
mends that after the patient has been anaesthetized the opening- should 
be dilated so as to admit the finger, by which the septa between the vari- 
ous sinuses should be broken down and a large -ingle abscess-cavity 
made. This should then be thoroughly irrigated with a 3 per cent, 
solution of carbolic acid, a drainage-tube introduced, and the ordinary 
antiseptic dressings applied. As the drain on the system i- great and 
the constitutional debility generally pronounced, much attention must be 
paid to general treatment, and abundance of nourishing food, appropri- 
ate stimulants, and such medicines as iron and quinine will be indicated. 

Hand- Feeding. — In a considerable number of cases the inability of 
the mother to nurse the child, her invincible repugnance to a wet-nurse, 
or inability to bear the expense renders hand-feeding essential. It i- 
therefore of importance that the accoucheur should be thoroughly famil- 
iar with the best method of bringing up the child by hand, so a- t«» be 
able to direct the process in the way that is most likely t<> be successful. 

Causes of Mortality in Hand-fed Children. — Much of the mortality 
following hand-feeding may be traced to unsuitable food. Among the 
poorer classes especially there is a prevalent notion that milk alone is 
insufficient, and hence the almost universal custom of administering 
various farinaceous foods, such a- corn flour or arrowroot, even from 
the earliest period. Many of these consisl of starch alone, and are 
therefore absolutely unsuited for forming the staple of diet <>n account 
of the total absence of nitrogenous elements, [ndependently of this, it 
has been shown that the saliva of infants baa not the same digestive 
property on starch that it subsequently acquires, and this affords a fur- 
ther explanation of its so constantly producing intestinal derangement. 
Reason, as well as experience, abundantly proves that the^ object to be 

aimed at in hand-feeding is to imitate a- nearly M possible the \]»»\ 
which nature supplies for the new-born child, and therefore the obvious 
course is to use milk from some animal, -«» treated ;i- 1" make it resemble 
human milk as nearly as may be. 

Ass's Milk.— Of the various milks used, that of the ass, on the whole, 



570 THE PUERPERAL STATE. 

most closely resembles human milk, containing less casein and butter 
and more saline ingredients. It is not always easy to obtain, and in 
towns is excessively expensive. Moreover, it does not always agree with 
the child, being apt to produce diarrhoea. We can, however, be more 
certain of its being unadulterated, which in large cities is in itself no 
small advantage, and it may be given without the addition of water or 
sugar. 

Goafs Milk. — Goat's milk in this country is still more difficult to 
obtain, but it often succeeds admirably. In many places the infant 
sucks the teat directly, and certainly thrives well on the plan. 

[We reverse the order in this country, where the ass is seldom seen 
and the goat is quite common, particularly in the suburbs of our large 
cities, where its milk is most required. I have seen marvellous results 
from feeding sick infants with its milk freshly drawn and diluted with 
hot water. I do not believe it is as suitable as that of the cow, but it 
has the advantage that it can be obtained freshly drawn in a city by 
keeping the animal in the yard or on a vacant lot. The goat should be 
fed upon grass and other suitable diet, and not permitted to run at large, 
as it eats with impunity stramonium and other noxious weeds. — Ed.] 

Cow's Milk, and its Preparation. — In a large majority of cases we 
have to rely on cow's milk alone. It differs from human milk in con- 
taining less water, a larger amount of casein and solid matters, and less 
sugar. Therefore, before being given it requires to be diluted and 
sweetened. A common mistake is over-dilution, and it is far from rare 
for nurses to administer one-third cow's milk to two-thirds water. The 
result of this excessive dilution is that the child becomes pale and puny 
and has none of the firm and plump appearance of a well-fed infant. 
The practitioner should therefore ascertain that this mistake is not being 
made ; and the necessary dilution will be best obtained by adding to 
pure fresh cow's milk one-third hot water, so as to warm the mixture to 
about 96°, the whole being slightly sweetened with sugar of milk or 
ordinary crystallized sugar. After the first two or three months the 
amount of Avater may be lessened, and pure milk, warmed and sweet- 
ened, given instead. Whenever it is possible the milk should be ob- 
tained from the same cow, and in towns some care is requisite to see that 
the animal is properly fed and stabled. Of late years it has been cus- 
tomary to obviate the difficulties of obtaining good fresh milk by using 
some of the tinned milks now so easily to be had. These are already 
sweetened, and sometimes answer well if not given in too weak a dilu- 
tion. One great drawback in bottle-feeding is the tendency of the milk 
to become acid, and hence to produce diarrhoea. This may be obviated 
to a great extent by adding a tablespoonful of lime-water to each bottle, 
instead of an equal quantity of water. 

[The milk of the Aldernev cow contains too much batter to make a 
good substitute for human milk in feeding young infants, and will often 
disagree with them when that of the common cow will be digested. 
The milk of one cow, which should neither be young or olcT, is to be 
preferred, but it must be borne in mind that the special can is often filled 
from the general supply. — Ed.] 

Artificial Human Milk. — An admirable plan of treating cow's milk, 



MANAGEMENT OF THE IS FAST, LACTATION, ETC. 071 

so as to reduce it to almost absolute chemical identity with human milk, 
has been devised by Professor Frankland, to whom I am indebted for 
permission to insert the recipe. I have followed this method in many 
cases, and find it far superior to the usual one, as it produces an exact 
and uniform compound. With a little practice nurses can employ it 
with no more trouble than the ordinary mixing of cow's milk with water 
and sugar. The following extract from Dr. Frankland's work ■ will 
explain the principles on which the preparation of the artificial human 
milk is founded : " The rearing of infants who cannot be .-applied with 
their natural food is notoriously difficult and uncertain, owing chiefly to 
the great difference in the chemical composition of human milk and 
cow's milk. The latter is much richer in casein and poorer in milk- 
sugar than the former, whilst ass's milk, which is sometimes used for 
feeding infants, is too poor in casein and butter, although the proportion 
of sugar is nearly the same as in human milk. The relations of the 
three kinds of milk to each other are clearly seen from the following 
analytical numbers, which express the percentage amounts of the different 
constituents : 

Woman. Ass. Cow. 

Casein 2.7 1.7 4. '1 

Butter :io 1.3 3.8 

Milk-sugar 5.0 4.5 3.8 

Salts 2 .5 .7 

These numbers show that by the removal of one-third of the casein from 
cow's milk, and the addition of about one-third more milk-sugar, a 
liquid is obtained which closely approaches human milk in composi- 
tion, the percentage amounts of the four chief constituents being as fol- 
lows : 

< asein 2.8 

Butter 3.8 

Milk-sugar 5.0 

Salts . - ! 

The following is the mode of preparing the milk : Allow one-third of a 
pint of new milk to stand for about twelve hours; remove the cream, 
and add to it two-thirds of a pint of new milk, as fresh from the <«»w as 
possible. Into the one-third of a pint of bine milk left after the 
abstraction of the cream put a piece of rennet about one inch square. 
Set the vessel in warm water until the milk i- fully curdled — an opera- 
tion requiring from live to fifteen minute-, according t<> the activity <»t 
the rennet, which should be removed a- Boon a- the curdling commences 
and put into an egg-cup for use on subsequent occasions, a- it may be 
employed daily for a month or two. Break up the curd repeatedly, and 
carefully separate the whole of the whey, which should then be rapidly 
heated to boiling in a .-mall tin pan placed over a -pirit or gas lamp. 
Diirin"- the heating a further quantity of casein, technically called * fleet- 



's i 



ings, J separates, and must be removed by straining through muslin. 
Now dissolve L 10 grains of powdered sugarofniilk in the hot whey, and 

mix it with the two-thirds of a pint of new mills t«> which the i 
from the other third of a pint was added as already described. The 
1 Frankland's Experimental II earchei in Chemistry, p 



572 THE PUERPERAL STATE. 

artificial milk should be used within twelve hours of its preparation^ 
and it is almost needless to add that all the vessels employed in its manu- 
facture and administration should be kept scrupulously clean." 1 

Method of Hand-feeding. — Much of the success of bottle-feeding must 
depend on minute care and scrupulous cleanliness — points which cannot 
be too strongly insisted on. Particular attention should be paid to pre- 
paring the food fresh for every meal, and to keeping the feeding-bottle 
and tubes constantly in water when not in use, so that minute particles 
of milk may not remain about them and become sour. A neglect of this 
is one of the most fertile sources of the thrush from which bottle-fed 
infants often suffer. The particular form of bottle used is not of much 
consequence. Those now commonly employed, with a long india-rubber 
tube attached, are preferable to the older forms of flat bottle, as they 
necessitate strong suction on the part of the infant, thus forcing it to 
swallow the food more slowly. Care must be taken to give the meals 
at stated periods, as in breast-feeding, and these should be at first about 
two hours apart, the intervals being gradually extended. The nurse 
should be strictly cautioned against the common practice of placing the 
bottle beside the infant in its cradle and allowing it to suck to repletion 
— a practice which leads to over-distension of the stomach and conse- 
quent dyspepsia. The child should be raised in the arms at the proper 
time, have its food administered, and then be replaced in the cradle to 
sleep. In the first few weeks of bottle-feeding constipation is very com- 
mon, and may be effectually remedied by placing as much phosphate of 
soda as will lie on a threepenny-piece in the bottle two or three times in 
the twenty-four ho^rs. 

Other Kinds of Food. — If this system succeed, no other food should 
be given until the child is six or seven months old, and then some of 
the various infant's foods may be cautiously commenced. Of these 
there are an immense number in common use, some of which are good 
articles of diet, others are unfitted for infants. In selecting them we 
have to see that they contain the essential elements of nutrition in proper 
combination. All those, therefore, that are purely starchy in character, 
such as arrowroot, corn flour, and the like, should be avoided, while 
those that contain nitrogenous as well as starch elements may be safely 
given. Of the latter the entire wheat flour, which contains the husks 
ground down with the wheat, generally answers admirably ; and of the 
same character are rusks, tops and bottoms, Nestle' s or Liebig's infant's 

1 The following recipe yields the same results, but the method is easier, and I find 
that nurses prepare the milk with less difficulty when it is followed : " Take half a 
pint of skimmed milk, heat it to about 96°, and put into the warmed milk a piece of 
rennet about an inch square. Set the milk to stand in the fender or over a lamp until 
it is quite warm. When it is set, take the rennet out and break up the curd quite 
small with a knife, and let it stand ten or fifteen minutes, when the curd will sink. 
Then pour the whey into a saucepan, and let it boil quickly. Measure one-third of a 
pint of this whey, and dissolve in it, when hot, a powder containing 110 grains of sugar 
of milk. When this third of a pint of whey is quite cold add to it two-thirds of a pint of 
new milk and two teaspoonfuls of cream, stirring the whole together. The food should 
be made fresh every twelve hours, and warmed as required. The piece of rennet when 
taken out can be kept in an egg-cup and used for ten days or a fortnight." — N. B. It is 
often advisable during the first month to use rather more than a third of a pint of 
whey, as the milk is apt to be rather too rich for a newly-born child. 



PUERPERAL ECLAMPSIA. 573 

food, and many others. If the child be pale and flabby, some more 
purely animal food may often be given twice a day, and great benefit 
may be derived from a single meal of beef, chicken, or veal tea, with a 
little bread-crumb in it, especially after the sixth or seventh month. 
Milk, however, should still form the main article of diet, and should 
continue to do so for many months. 

Management ichen Milk Disagrees. — If the child be pale, flabby, and 
do not gain flesh, more especially if diarrhoea or other intestinal dis- 
turbance be present, we may be certain that hand-feeding is not answer- 
ing satisfactorily and that some change is required. If the child be not 
too old and will still take the breast, that is certainly the best remedy, 
but if that be not possible it is necessary to alter the diet. When milk 
disagrees, cream, in the proportion of one tablespoonful to three of 
water, sometimes answers as well. Occasionally also Liebig's or Mel- 
lin's infant's food, when carefully prepared, renders good service. Too 
often, however, when once diarrhoea or other intestinal disturbance lias 
set in, all our efforts may prove unavailing, and the health, if not the 
life, of the infant becomes seriously imperilled. It is not, however, 
within the scope of this work to treat of the disorders of infants at the 
breast, the proper consideration of which requires a large amount of 
space, and I therefore refrain from making any further remarks on the 
subject. 



CHAPTER III. 

PUERPERAL ECLAMPSIA. 



By the term puerperal eclampsia is meant a peculiar kind of epilepti- 
form convulsions which may occur in the latter mouth- of pregnancy or 
during or after parturition, and it constitutes one of the most formidable 
diseases with which the obstetrician has to cope. The attack i- often BO 
sudden and unexpected, SO terrible in its nature, ami attended with such 
serious danger both to the mother and child, that the disease has 
attracted much attention. 

Its Doubtful Etiology. — The researches of Lever, Braun, Prerichs, 
and many other writers who have shown the tre<|iient association "i" 
eclampsia with albuminuria have, of late years, been -u|»|><.-««l t.. clear 
up to a great extent the < tiology of the < I i-« :i-< •, and t«> prove it- depend- 
ence on the retention of urinary element- in the blood. \\ hile the uri- 
nary origin of eclampsia has been pretty generally accepted, more recenl 
observations have tended to throw doubl on its essential dependen* 
this cause, so that it can hardly be said thai we are yet in :i position to 
explain its true pathology with certainty. These points will require 
separate discussion, but it is first necessary t" describe the character and 
history of the attack. 



574 THE PUERPERAL STATE. 

Considerable confusion exists in the description of puerperal convul- 
sions from the confounding of several essentially distinct diseases under 
the same name. Thus, in most obstetric works it has been customary 
to describe three distinct classes of convulsion — the epileptic, the hyster- 
ical, and the apoplectic. The two latter, however, come under a totally 
different category. A pregnant woman may suffer from hysterical par- 
oxysms, or she may be attacked with apoplexy, accompanied with coma 
and followed by paralysis. But these conditions in the pregnant or 
parturient woman are identical with the same diseases in the non-preg- 
nant, and are in no way special in their nature. True eclampsia, how- 
ever, is different in its clinical history from epilepsy, although the par- 
oxysms, while they last, are essentially the same as those of an ordinary 
epileptic fit. 

Premonitory Symptoms. — An attack of eclampsia seldom occurs with- 
out having been preceded by certain more or less well-marked precur- 
sory symptoms. It is true that in a considerable number of cases these 
are so slight as not to attract attention, and suspicion is not aroused 
until the patient is seized with convulsions. Still, subsequent investiga- 
tions will very generally show that some symptoms did exist, which, if 
observed and properly interpreted, might have put the practitioner on 
his guard and possibly have enabled him to ward off the attack. Hence 
a knowledge of them is of real practical value. The most common are. 
associated with the cerebrum, such as severe headache, which is the one 
most generally observed and is sometimes limited to one side of the head. 
Transient attacks of dizziness, spots before the eyes, loss of sight, or 
impairment of the intellectual faculties are also not uncommon. These 
signs in a pregnant woman are of the gravest import, and should at 
once call for investigation into the nature of the case. Less marked 
indications sometimes exist in the form of irritability, slight headache 
or stupor, and a general feeling of indisposition. Another important 
premonitory sign is oedema of the subcutaneous cellular tissue, especially 
of the face or upper extremities, which should at once lead to an exam- 
ination of the urine. 

Symptoms of the Attack. — Whether such indications have preceded an 
attack or not, as soon as the convulsion comes on there can no longer be 
any doubt as to the nature of the case. The attack is generally sudden 
in its onset, and in its character is precisely that of a severe epileptic fit 
or of the convulsions in children. Close observation shows that there 
is at first a short period of tonic spasm, affecting the entire muscular 
system. This is almost immediately succeeded by violent clonic con- 
tractions, generally commencing in the muscles of the face, which twitch 
violently ; the expression is horribly altered ; the globes of the eyes are 
turned up under the eyelids, so as to leave only the white sclerotics vis- 
ible ; and the angles of the mouth are retracted and fixed in a convulsive 
grin. The tongue is at the same time protruded forcibly, and, if care 
be not taken, is apt to be lacerated by the violent grinding of the teeth. 
The face, at first pale, soon becomes livid and cya nosed, while the veins 
of the neck are distended and the carotids beat vigorously. Frothy 
saliva collects about the mouth, and the whole appearance is so changed 
as to render the patient quite unrecognizable. The convulsive move- 



PUERPERAL ECLAMPSIA. 575 

ments soon attack the muscles of the body. The hands and arm-, at 
first rigidly fixed, with the thumbs clenched into the palms, begin bo 
jerk, and the whole muscular system is thrown into rapidly-recurring 
convulsive spasms. It is evident that the involuntary muscles are im- 
plicated in the convulsive action, as well as the voluntary. This is 
shown by a temporary arrest of respiration at the commencement of the 
attack, followed by irregular and hurried respiratory movements, pro- 
ducing a peculiar hissing sound. The occasional involuntary expulsion 
of urine and feces indicates the same fact. During the attack the patient 
is absolutely unconscious, sensibility is totally suspended, and she has 
afterward no recollection of what has taken place. Fortunately, the 
convulsion is not of long duration, and at the outside docs not la>t more 
than three or four minutes, generally not so long. In most cases, after 
an interval there is a recurrence of the convulsion, characterized by t In- 
sane phenomena, and the paroxysms are repeated with more or less force 
and frequency according to the severity of the attack. Sometimes sev- 
eral hours may elapse before a second convulsion comes on ; at others 
the attacks may recur very often, with only a few minutes between them. 
In the slighter forms of eclampsia there may not be more than two or 
three paroxysms in all; in the more serious as many as fifty or sixty 
have been recorded. 

Condition between the Attacks. — After the first attack the patient gen- 
erally soon recovers her consciousness, being somewhat dazed and som- 
nolent, with no clear conception of what has" occurred. If the parox- 
ysms be frequently repeated, more or less profound coma continues in 
the intervals between them ; which no doubt depends upon intense cere- 
bral congestion, resulting from the interference with the circulation in 
the great veins of the neck, produced by spasmodic contraction of the 
muscles. The coma is rarely complete, the patient showing signs of 
sensibility when irritated, and groaning during the uterine contractions. 
In the worst class of cases the torpor may become Intense and continu- 
ous, and in this state the patient may die. When the convulsions have 
entirely stopped and the patient has completely regained her conscious- 
ness, and is apparently convalescent, recollection of what has taken 
place during and some time before the attack may be entirely losl ; and 
this condition may last for a considerable time. A curious instance of 
this once came under my notice in a lady who had losl her brother, t<> 
whom she was greatly attached, in the week immediately preceding her 
confinement, and in whom the mental distress seemed t<> have had m good 
deal to do in determining the attack. It was many week- before she 
recovered her memory, and during that time die recollected nothing 
about the circumstances connected with her brother's death, the whole 

of that week being as it were blotted out of her recollection. 

Relation of the Attacks to Labor. — II' the convulsions come on during 
pregnancy, we may look upon the advent of labor a- almost a certainty ; 
and if we consider the >v\vve nervous Bhock and genera] disturbance, 
this is the resull we mighl reasonably anticipate, [f they occur, ae is 
not uncommon, for the first time during labor, the pains generally 
tinue with increased force and frequency, since the uterus partakes <»f 
the convulsive action. It has not rarely happened that the pains have 



576 THE PUERPERAL STATE. 

gone on with such intensity that the child has been born quite unex- 
pectedly, the attention of the practitioner being taken up with the pa- 
tient. In many cases the advent of fresh paroxysms is associated with 
the commencement of a pain, the irritation of which seems sufficient to 
bring on the convulsion. 

Results to the Mother and Child. — The results of eclampsia vary 
according to the severity of the paroxysms. It is generally said that 
about 1 in 3 or 4 cases dies. The mortality has certainly lessened of 
late years, probably in consequence of improved knowledge of the 
nature of the disease and more rational modes of treatment. This is 
well shown by Barker, 1 who found in 1855 a mortality of 32 per cent, 
in cases occurring before and during labor, and 22 per cent, in those 
after labor, while since that date the mortality has fallen to 14 per cent. 
The same conclusion is arrived at by Dr. Phillips, 2 who has shown that 
the mortality has greatly lessened since the practice of repeated and in- 
discriminate bleeding, long considered the sheet-anchor in the disease, 
has been discontinued and the administration of chloroform substituted. 

Cause of Death. — Death may occur during the paroxysm, and then it 
may be due to the long continuance of the tonic spasm producing as- 
phyxia. It is certain that as long as the tonic spasm lasts the respira- 
tion is suspended, just as in the convulsive disease of children known as 
laryngismus stridulus ; and it is possible also that the heart may share 
in the convulsive contraction which is known to affect other involuntary 
muscles. More frequently death happens at a later period, from the 
combined effects of exhaustion and asphyxia. The records of post-mor- 
tem examinations are not numerous ; in those we possess the principal 
changes have been an anaemic condition of the brain, with some oedema- 
tous infiltration. In a few rare cases the convulsions have resulted in 
effusion of blood into the ventricles or at the base of the brain. The 
prognosis as regards the child is also serious. Out of 36 children, Hall 
Davis found 26 born alive, 10 being stillborn. There is good reason to 
believe that the convulsion may attack the child in utero — of this several 
examples are mentioned by Cazeaux — or it may be subsequently attacked 
with convulsions, even when apparently healthy at birth. 

Pathology of the Disease. — The precise pathology of eclampsia cannot 
be considered by any means satisfactorily settled. When, in the year 
1843, Lever first showed that the urine in patients suffering from puer- 
peral convulsions was generally highly charged with albumen — a fact 
which subsequent experience has amply confirmed — it was thought that 
a key to the etiology of the disease had been found. It was known that 
chronic forms of Bright' s disease were frequently associated with reten- 
tion of urinary elements in the blood and not rarely accompanied by 
convulsions. The natural inference was drawn that the convulsions of 
eclampsia were also due to toxaemia resulting from the retention of urea 
in the blood, just as in the uraemia of chronic Bright's disease; and this 
view was adopted and supported by the authority of Braun, Frerichs, 
and many other writers of eminence, and was generally received as a 
satisfactory explanation of the facts. Frerichs modified it so far that 
he held that the true toxic element was not urea as such, but carbonate 

1 The Puerperal Diseases, p. 125. 2 Guy's Hospital Reports, 1870. 



PUERPERAL ECLAMPSIA. 577 

of ammonia, resulting from its decomposition, and experiments were 
made to prove that the injection of this substance into the veins of the 
lower animals produced convulsions of precisely the same character as 
eclampsia. Dr. Hammond 1 of Maryland subsequently made a series of 
counter-experiments, which were held as proving that there was no rear 
son to believe that urea ever did become decomposed in the blood in 
the way that Frerichs supposed, or that the symptoms of uraemia were 
ever produced in this way. Others have believed that the poisonous 
elements retained in the blood are not urea or the products of its decom- 
position, but other extractive matters which have escaped detection. As 
time elapsed, evidence accumulated to show that the relation between 
albuminuria and eclampsia Avas not so universal as was supposed, or at 
least that some other factors were necessary to explain many of the 
cases. Xumerous cases were observed in which albumen was detected 
in large quantities, without any convulsion following, and that not only 
in women who had been the subject of Bright's disease before concep- 
tion, but also when the albuminuria was known to have developed dur- 
ing pregnancy. Thus, Imbert Goubeyre found that, out of 1<)4 cases 
of the latter kind, 95 had no eclampsia, and Blot, out of 41 cases, found 
that 34 were delivered without untoward symptoms. It may be taken 
as proved, therefore, that albuminuria is by no means necessarily accom- 
panied by eclampsia. Cases were also observed in which the albumen 
only appeared after the convulsion, and in these it was evident that the 
retention of urinary elements could not have been the cause of the 
attack ; and it is highly probable that in them the albuminuria was pro- 
duced by the same cause which induced the convulsion. Special atten- 
tion has been called to this class of cases by Braxton Hicks, 2 who has 
recorded a considerable number of them. He says that the nearly simul- 
taneous appearance of albuminuria and convulsion — and it is admitted 
that the two are almost invariably combined — must then be explained 
in one of three ways : 

1st. That the convulsions are the cause of the nephritis. 

2dlv. That the convulsions and the nephritis are produced by the 
same cause — e. g. some detrimental ingredient circulating in the blood, 
irritating both the cerebro-spinal system and other organ- at the same 
time. 

3dly. That the highly-congested state of* the venous system, induced 
by the spasm of the glottis in eclampsia, is able to produce the kidney 
complication. 

Theory of Travbe <tn<i Rosenstein. — More recently, Traube and Etosenr 
stein have advanced a theory of eclampsia purporting t<> explain these 
anomalies. They refer the occurrence of eclampsia to acute cerebral 
anaemia resulting from changes in the blood incident to pregnancy. The 
primary factor is the hydraemic condition <»f the blood w hicn is an ordin- 
ary concomitant of* the pregnant -late, and of course when there is also 
albuminuria the watery condition of the U".».| is greatly intensified ; 
hence the frequent association of the two states. Accompanying this 
condition of the blood there i- increased tension of the arterial system, 
which is favored by the hypertrophy of the heart which i- known to be 

1 Amer. Jaurn^ 1801. '' v "' viii - 

37 



578 THE PUERPERAL STATE. 

a normal occurrence in pregnancy. The result of these combined states 
is a temporary hyperemia of the brain, which is rapidly succeeded by 
serous effusion into the cerebral tissues, resulting in pressure on its mi- 
nute vessels and consequent anaemia. There is much in this theory that 
accords with the most recent views as to the etiology of convulsive dis- 
ease ; as, for example, the researches of Kussmaul and Tenner, who had 
experimentally proved the dependence of convulsion on cerebral anaemia, 
and of Brown-Sequard, who showed that an anaemic condition of the 
nerve-centres preceded an epileptic attack. It explains also very satis- 
factorily how the occurrence of labor should intensify the convulsions, 
since during the acme of the pains the tension of the cerebral arterial 
system is necessarily greatly increased. There are, however, obvious 
difficulties against its general acceptance. For example, it does not 
satisfactorily account for those cases which are preceded by well-marked 
precursory symptoms, and in which an abundance of albumen is present 
in the urine. Here the premonitory signs are precisely those which 
precede the development of uraemia in chronic Bright's disease, the 
dependence of which on the retention in the blood of urinary elements 
can hardly be doubted. Moreover, it has been shown by Lohlein and 
others that on post-mortem examination the brain does not, as a rule, 
exhibit the oedema, anaemia, and flattened convolutions which this theory 
assumes. 

Views of MacDonald. — MacDonald 1 has published an interesting 
paper on this subject, in which he describes two very careful post-mortem 
examinations. In these he found extreme anaemia of the cerebro-spinal 
centres, with congestion of the meninges, but no evidence of oedema. 
He inclines to the belief that eclampsia is caused by irritation of the 
vaso-motor centre in consequence of an anaemic condition of the blood 
produced by the retention in it of excrementitious matters which the 
kidneys ought to have removed, this over-stimulation resulting in 
anaemia of the deeper-seated nerve-centres and consequent convulsion. 

Excitability of Nervous System. — This key to the liability of the puer- 
peral woman to convulsive attacks is no doubt to be found in the pecu- 
liar excitable condition of the nervous system in pregnancy — a fact 
which was clearly pointed out by the late Dr. Tyler Smith and by many 
other writers. Her nervous system is in this respect not unlike that of 
children, in whom the predominant influence and great excitability of 
the nervous system are well-established facts, and in whom precisely 
similar convulsive seizures are of common occurrence on the application 
of a sufficiently exciting cause. 

Exciting Causes. — Admitting this, we require some cause to set the 
predisposed nervous system into morbid action ; and this we may have 
either in a toxaemic or in an extremely watery condition of the blood, 
associated with albuminuria ; or along with these, or sometimes inde- 
pendently of them, in some excitement, such as strong emotional disturb- 
ance. It is highly probable, however, that extreme anaemia is one of 
the actual conditions of the nerve-centres — a fact of much practical 
importance in reference to treatment. 

1 See his volume of collected essavs entitled Heart Disease during Pregnancy, London, 

1878. 



PUERPERAL ECLAMPSIA. 579 

Treatment. — The management of cases in which the occurrence of sus- 
picious symptoms has led to the detection of albuminuria, has already 
been fully discussed (p. 209). We shall therefore here only consider the 
treatment of cases in which convulsions have actually occurred. 

Venesection. — Until quite recently venesection was regarded as the 
sheet-anchor in the treatment, and blood was always removed copiously, 
and, there is sufficient reason to believe, with occasional remarkable bene- 
fit. Many cases are recorded in which a patient in apparently profound 
coma rapidly regained her consciousness when blood was extracted in 
sufficient quantity. The improvement, however, was often transient, 
the convulsions subsequently recurring with increased vigor. There are 
good theoretical grounds for believing that bloodletting can only be of 
merely temporary use, and may even increase the tendency to convulsion. 
These are so well put by Schroeder that I cannot do better than quote 
his observations on this point. " If," he says, "the theory of Traube 
and Rosenstein be correct, a sudden depletion of the vascular system, 
by which the pressure is diminished, must stop the attacks. From 
experience it is known that after venesection the quantity of blood soon 
becomes the same through the serum taken from all the tissues, while 
the quality is greatly deteriorated by the abstraction of blood. A short 
time after venesection we shall expect to find the former blood-pressure 
in the arterial system, but the blood far more watery than previously. 
From this theoretical consideration it follows that abstraction of blood, 
if the above-mentioned conditions really cause convulsions, must be 
attended by an immediate favorable result, and under certain circum- 
stances the whole disease may surely be cut short by it. But if all other 
conditions remain the same the blood-pressure will after some time again 
reach its former height. The quality of blood has in the mean time been 
greatly deteriorated, and consequently the danger of the disease will be 
increased." 

These views sufficiently well explain the varying opinions held with 
regard to this remedy, and enable us to understand why, while the 
effects of venesection have been so lauded by certain authors, the mor- 
tality has admittedly been much lessened since it> indiscriminate use has 
been abandoned. It does not follow because a remedy, when carried t<> 
excess, is apt to be hurtful, that it should be discarded altogether; and 
I have no doubt that in properly-selected cases and judiciously employed, 
venesection is a valuable aid in the treatment of eclampsia, and that ii is 
specially likely to be useful in mitigating the firsi violence ol* the attack 
and in giving time for other remedies to conic into action. < 5are should, 
however, be taken to select the cases properly, and it will be specially 
indicated when there is marked evidence of greal cerebral congestion 
and vascular tension, such as a livid Pace, a lull bounding pulse, and 
strong pulsation in the carotid-. The general constitution of the patient 
may also serve as a guide in determining its use, and we Bhall be me 
more disposed to resort to it if the patient be a strong and healthy woman ; 

while, on the other hand, if -he be feeble and weak we ma\ wi~.lv dis- 
card it and trust entirely to other means. [nanycase,i1 must !><■ looked 
upon as a temporary expedient only, useful in warding off immediate 
danger to the cerebral tissues, but never a- the main Bgenl in treatment. 



580 THE PUERPERAL STATE. 

Nor can it be permissible to bleed in the heroic manner frequently recom- 
mended. A single bleeding, the amount regulated by the effect produced, 
is all that is ever likely to be of service. 

[After the discovery of the ursemic origin of eclampsia in pregnant 
women the treatment by bleeding was very generally abandoned in the 
United States ; but the more recent investigations of the causes of death 
have produced a reconsideration of this plan of treatment, and the tend- 
ency of the profession during the last ten or fifteen years has been toward 
venesection as a preventive of cerebral complications. In primiparse 
with a full pulse and flushed face the rule with many of our obstetrical 
practitioners is to bleed the patient as early as practicable, and to do this 
at least once effectually, so as to produce, if possible, a noticeable impres- 
sion. Where there are positive evidences of the existence of Bright's 
disease, of course this is inadmissible. — Ed.] 

Compression of the Carotids. — As a temporary expedient, having the 
same object in view, compression of the carotids during the paroxysms 
is worthy of trial. This was proposed by Trousseau in the eclampsia 
of infants, and in the single case of eclampsia in which I have tried it 
seemed to be decidedly beneficial. It is a simple measure, and it offers 
the advantage of not leading to any permanent deterioration of the blood, 
as in venesection. 

Administration of Purgatives. — As a subsidiary means of diminishing 
vascular tension the administration of a strong purgative is desirable, 
and has the further effect of removing any irritant matter that may be 
lodged in the intestinal tract. If the patient be conscious, a full dose of 
the compound jalap poAvder may be given, or a few grains of calomel 
combined with jalap ; and if she be comatose and unable to swallow, a 
drop of croton oil or a quarter of a grain of elaterium may be placed on 
the back of the tongue. 

Administration of Sedatives and Narcotics. — The great, indication in 
the management of eclampsia is the controlling of convulsive action by 
means of sedatives. Foremost amongst them must be placed the inha- 
lation of chloroform — a remedy which is frequently remarkably useful, 
and which has the advantage of being applicable at all stages of the dis- 
ease and whether the patient be comatose or not. Theoretical objections 
have been raised against its employment, as being likely to increase 
cerebral congestion : of this there is no satisfactory proof; on the con- 
trary, there is reason to think that chloroform inhalation has rather the 
effect of lessening arterial tension, while it certainly controls the violent 
muscular action by which the hyperemia is so much increased. Practi- 
cally, no one who has used it can doubt its great value in diminishing 
the force and frequency of the convulsive paroxysms. Statistically, its 
usefulness is shown by Charpentier in his thesis on the effects of various 
methods of treatment in eclampsia, since, out of 63 cases in which it 
was used, in 48 it had the effect of diminishing or arresting the attacks, 
1 only proving fatal. The mode of administration has varied. Some 
have given it almost continuously, keeping the patient in a more or less 
profound state of anaesthesia. Others have contented themselves with 
carefully watching the patient, and exhibiting the chloroform as soon as 
there were any indications of a recurring paroxysm, with the view of 



PUERPERAL ECLAMPSIA. 581 

controlling its intensity. The latter is the plan I have myself adopted, 
and of the value of which in most cases I have no doubt/ Every now 
and again cases will occur in which chloroform inhalation is insufficient 
to control the paroxysm, or in which, from the very cyanosed state of 
the patient, its administration seems contraindicated. Moreover, it is 
advisable to have, if possible, some remedy more continuous in its action 
and requiring less constant personal supervision. Latterly, the internal 
administration of chloral has been recommended for this purpose. My 
own experience is decidedly in its favor, and I have used, as I believe, 
with marked advantage a combination of chloral with bromide of potas- 
sium, in the proportion of twenty grains of the former to half a drachm 
of the latter, repeated at intervals of from four to six hours. If the 
patient be unable to swallow, the chloral may be given in an enema or 
hypodermically, six grains being diluted in 3j of water and injected 
under the skin. The remarkable influence of bromide of potassium in 
controlling the eclampsia of infants would seem to be an indication for 
its use in puerperal cases. Fordyce Barker is opposed to the use of 
chloral, which he thinks excites instead of lessens reflex irritability. 1 
Another remedy, not entirely free from theoretical objections, but strongly 
recommended, is the subcutaneous injection of morphia, which has the 
advantage of being applicable when the patient is quite unable to -wal- 
low. It may be given in doses of one-third of a grain, repeated in a 
few hours, so as to keep the patient well under its influence. It i- to be 
remembered that the object is to control muscular action, so a- to pre- 
vent as much as possible the violent convulsive paroxysm, and therefore 
it is necessary that the narcosis, however produced, should be continuous. 
It is rational, therefore, to combine the intermittent action of chloroform 
with the more continuous action of other remedies, so that the former 
should supplement the latter when insufficient. Inhalation of the nitrite 
of amyl has been recommended on physiological grounds as likely to be 
useful, and is well worthy of trial, but of its action I have as yet no 
personal experience. Pilocarpine has recently been tried in the hope 
that the diaphoresis and salivation it produces might diminish arterial 
tension and free the blood of toxic matte]--. Miami- administered 3 
centigramme- of the muriate of pilocarpine hypodermically, and reports 
favorably of the result; Fordyce Barker,' 5 however, is of opinion that 
it produces so much depression as to be dangerous. 

Other remedies, supposed to act in the way of antidotes to uremic 
poisoning, have been advised, such a- acetic or benzoic acid, but tiny are 
far too uncertain to have any reliance placed on them, and they distract 
attention from more useful measures. 

Precautions during the Paroxysm, — Precautions are necessary during 
the fits to prevent the patient injuring herself, especially t.. obviate lace- 
ration of the tongue j the latter" can !><• best done by placing something 
between the teeth a- the paroxysm comes on, such a- the handle <•! a 
teaspoon enveloped in several folds of flannel. 

Obstetric Management — The obstetric management of •■••lamp i:i will 
naturally give rise to much anxiety, and on this point then- ha- been 

1 The Puerperal Disease*, p. 120. R - .W <.. June l'">. I 

9 New York Med. Ree. } March 1. 1879. 



582 THE PUERPERAL STATE. 

considerable difference of opinion. On the one hand, we have prac- 
titioners who advise the immediate emptying of the uterus, even when 
labor has commenced ; on the other, those who would leave the labor 
entirely alone. Thus Gooch said, " Attend to the convulsions and leave 
the labor to take care of itself ;" and Schroeder says, " Especially no 
kind of obstetric manipulation is required for the safety of the mother ;" 
but he admits, however, that it is sometimes advisable to hasten the 
labor to ensure the safety of the child. 

In cases in which the convulsions come on during labor the pains are 
often strong and regular, the labor progresses satisfactorily, and no inter- 
ference is needful. In others we cannot but feel that emptying the uterus 
would be decidedly beneficial. We have to reflect, however, that any 
active interference might of itself prove very irritating and excite fresh 
attacks. The influence of uterine irritation is apparent by the frequency 
with which the paroxysms recur with the pains. If, therefore, the os be 
undilated and labor have not begun, no active means to induce it should 
be adopted, although the membranes may be ruptured with advantage, 
since that procedure produces no irritation. Forcible dilatation of the 
os, and especially turning, are strongly contraindicated. 

The rule laid down by Tyler Smith seems that which is most advis- 
able to follow — that we should adopt the course which seems least likely 
to prove a source of irritation to the mother. Thus, if the fits seem 
evidently induced and kept up by the pressure of the foetus, and the 
head be within reach, the forceps, or even craniotomy, may be resorted 
to. But if, on the other hand, there be reason to think that the ope- 
ration necessary to complete delivery is likely per se to prove a greater 
source of irritation than leaving the case to nature, then we should not 
interfere. 



CHAPTER IV. 

PUERPERAL INSANITY. 



Classification. — Under the head of "Puerperal Mania" writers on 
obstetrics have indiscriminately classed all cases of mental disease con- 
nected with pregnancy and parturition. The result has been unfor- 
tunate, for the distinction between the various types of mental disorder 
has, in consequence, been very generally lost sight of. But little study 
of the subject suffices to show that the term " puerperal mania" is wrong 
in more ways than one, for we find that a large number of cases are not 
cases of " mania" at all, but of melancholia ; while a considerable num- 
ber are not, strictly speaking, " puerperal," as they either come on dur- 
ing pregnancy or long after the immediate risks of the puerperal period 
are over, being in the latter case associated with anaemia produced by 
over-lactation. For the sake of brevity the generic term "Puerperal 
Insanity" may be employed to cover all cases of mental disorders con- 






PUERPERAL INSANITY. 583 

nected with gestation, which may be further conveniently subdivided 
into three classes, each having its special characteristics — viz. : 

I. The Insanity of Pregnancy. 

II. Puerperal Insanity, properly so called — that is, insanity coming 
on within a limited period after delivery. 

III. The Insanity of lactation. 

This division is a strictly natural one, and includes all the cases likely 
to come under observation. The relative proportion these classes bear 
to each other can only be determined by accurate statistical observations 
on a large scale, but these materials we do not possess. The returns 
from large asylums are obviously open to objection, for only the worst 
and most confirmed cases find their way into these institutions, while by 
far the greater proportion, both before and after labor, are treated in 
their own homes. 

Proportion of these Forms of Insanity. — Taking such returns as only 
approximate, we find from Dr. Batty Tuke 1 that in the Edinburgh 
Asylum, out of 155 cases of puerperal insanity, 28 occurred before 
delivery, 73 during the puerperal period, and 54 during lactation. The 
relative proportions of each per hundred are as follows : 

Insanity of Pregnancy, 18.06 per cent. 

Puerperal Insanity, 47.09 " 

Insanity of Lactation, 34.83 " 
Marce 2 collects together several series of cases from various authorities, 
amounting to 310 in all, and the results are not very different from 
those of the Edinburgh Asylum, except in the relatively smaller num- 
ber of cases occurring before delivery. The percentage is calculated 
from his figures : 

Insanity of Pregnancy, 8.06 per cent. 

Puerperal Insanity, 58.06 " 

Insanity of Lactation, 30.30 " 
As each of these classes differs in various important respects from the 
others, it will be better to consider each separately. 

Insanity of Pregnancy. — The insanity of pregnancy is, without 
doubt, the least common of the three forms. The intense mental de- 
pression which in many women accompanies pregnancy, and causes the 
patient to take a desponding view of her condition and to look forward 
to the result of her labor with the most gloomy apprehension, seems to 
be often only a lesser degree of the actual mental derangement which is 
occasionally met with. The relation between the two -tat'- is further 
borne out by the fact that a large majority of cases of insanity during 
pregnancy are well-marked types of melancholia : out of "_' s cases re- 
ported by Tuke, 15 were examples of pure melancholia, 5 of dementia 
with melancholia. In many of these the attack could be traced as de- 
veloping itself out of the ordinary hypochondriasis <>f pregnancy. In 
others the symptoms came on at a later period of pregnancy, tin- earlier 
months of which had not been marked by any unusual lowness of 
spirits. The ageof the patient seems to have some influence, the pro- 
portion of cases between 30 and 10 year- of age being much larger than 
in younger women. A larger proportion of cases occur in priniiparn 
1 Edin. Med. Journ.. vol. x. -' TraiU de l,< Folit rf< / ■ 



584 THE PUERPERAL STATE. 

than in multipara — a fact that no doubt depends on the greater dread 
and apprehension experienced by women who are pregnant for the first 
time, especially if not very young. Hereditary disposition plays an im- 
portant part, as in all forms of puerperal insanity. It is not always easy 
to ascertain the fact of an hereditary taint, since it is often studiously con- 
cealed by the friends. Tuke, however, found distinct evidence of it in 
no less than 12 out of 28 cases. Ftirstner 1 believes that other neuroses 
have an important influence in the causation of the disease. Out of 32 
cases he found direct hereditary taint in 9, but in 11 more there was a 
family history of epilepsy, drunkenness, or hysteria. 

Period of Pregnancy at which it Occurs. — The period of pregnancy at 
which mental derangement most commonly shows itself varies. Most 
generally, perhaps, it is at the end of the third or the beginning of the 
fourth month. It may, however, begin with conception, and even return 
with every impregnation. Montgomery relates an instance in which it 
recurred in three successive pregnancies. Marce distinguishes between 
true insanity coming on during pregnancy and aggravated hypochon- 
driasis by the fact that the latter usually lessens after the third month, 
while the former most commonly only begins after that date. It is 
unquestionable that in many cases no such distinction can be made, and 
that the two are often very intimately associated. 

Form of Insanity. — The form of insanity does not differ from ordinary 
melancholia. The suicidal tendency is generally very strongly developed. 
Should the mental disorder continue after delivery, the patient may very 
probably experience a strong impulse to kill her child. Moral perver- 
sions have not been uncommonly observed. Tuke especially mentions 
a tendency to dipsomania in the early months, even in women who have 
not shown any disposition to excess at other times. He suggests that 
this may be an exaggeration of the depraved appetite or morbid craving 
so commonly observed in pregnant women, just as melancholia may be 
a further development of lowness of spirits. Laycock mentions a dis- 
position to " kleptomania" as very characteristic of the disease. Casper 2 
relates a curious case where this occurred in a pregnant lady of rank, 
and the influence of pregnancy in developing an irresistible tendency was 
pleaded in a criminal trial in which one of her petty thefts had involved 
her. 

Prognosis. — The prognosis may be said to be, on the whole, favorable. 
Out of Dr. Tuke's 28 cases, 19 recovered within six months. There is 
little hope of a cure until after the termination of the pregnancy, as, out 
of 1 9 cases recorded by Marce, only in 2 did the insanity disappear before 
delivery. 

Transient Mania during Delivery. — There is a peculiar form of mental 
derangement sometimes observed during labor which is bv some talked 
of as a temporary insanity. It may, perhaps, be more accurately de- 
scribed as a kind of acute delirium, produced, in the latter stage of 
labor, by the intensity of the suffering caused by the pains. According 
to Montgomery, it is most apt to occur as the head is passing through 
the os uteri, or, at a later period, during the expulsion of the child. It 

1 Arch'vfur Psi/chiatrie, Band v. Heft 2. 

2 Casper's Forensic Medicine, New Syd. Soc, vol. iv. p. 308. 



PUERPERAL INSANITY. 585 

may consist of merely a loss of control over the mind, daring which the 
patient, unless carefully watched, might in her agony seriously injure 
herself or her child. Sometimes it produces actual hallucination, as in 
the case described by Tarnier in which the patient fancied she saw a 
spectre standing at the foot of her bed, which she made violent efforts to 
drive away. This kind of mania, if it may be so called, is merely transi- 
tory in its character, and disappears as soon as the labor is over. From 
a medico-legal point of view it may be of importance, as it has been held 
by some that in certain cases of infanticide the mother has destroyed the 
child when in this state of transient frenzy and when she was irresponsi- 
ble for her acts. In the treatment of this variety of delirium we must, 
of course, try to lessen the intensity of the suffering, and it is in such cases 
that chloroform will find one of its most valuable applications. 

Puerperal Insanity [proper). — True puerperal insanity has always 
attracted much attention from obstetricians, often to the exclusion of 
other forms of mental disturbance' connected with the puerperal state. 
We may define it to be that form of insanity which comes on within a 
limited period after delivery, and which is probably intimately connected 
with that process. Out of 73 examples of the disease tabulated by Dr. 
Tuke, only 2 came on later than a month after delivery, and in these 
there were other causes present which might possibly remove them from 
this class. 

Although a large number of these cases assume the character of acute 
mania, that is by no means the only kind of insanity which is observed, 
a not inconsiderable number being well-marked examples of melan- 
cholia. The distinction between them was long ago pointed oul by 
Gooch, whose admirable monograph on ths disease contain- one of tin- 
most graphic and accurate accounts of puerperal insanity that has yel 
been written. 

There are also some peculiarities as to the period at which these varie- 
ties of insanity show themselves, which, taken in connection with certain 
facts in their etiology, may eventually justify us in drawing a stronger 
line of demarcation between them than lias been usual. It appears that 
cases of acute mania are apt to come on at a period much oearer delivery 
than melancholia. Thus, Tuke found that all the cases of mania came 
on within sixteen days after delivery, and that all cases of melancholia 
developed themselves after that period. We shall presently see that one 
of the most recent theories a- to the causation of the disease attributes it 
to some morbid condition of the blood. Should further investigation 
confirm this supposition, inasmuch a- septic conditions of the blood 

are most likely to occur a short time alter labor, it would nol be an 

improbable hypothesis that cases of acute mania occurring within a BJiorl 
time after labor may depend on such septic causes, while melancholia i- 
more likely to arise' from general conditions fa voring the development 
of mental disease. This must, however, I" regardi «l as a mere specula- 
tion requiring further investigation. 

Causes. — Hereditary predisposition is very frequently met with, and 
a careful inquiry into 'the patient's history will generally she* thai 
members of the family have suffered from mental derangement 
found that out of 111 cases in Bethlehem Hospital there was clear evi- 



586 THE PUERPERAL STATE. 

dence of hereditary taint in 45. Tuke made the same observation in 22 
out of his 73 cases ; and, indeed, it is pretty generally admitted by all 
alienist physicians that hereditary tendencies form one of the strongest 
predisposing causes of mental disturbance in the puerperal state. In a 
large proportion of cases circumstances producing debility and exhaus- 
tion or mental depression have preceded the attack. Thus, it is often 
found that patients attacked with it have had post-partum hemorrhage, 
or have suffered from some other conditions producing exhaustion, such 
as severe and complicated labor, or they may have been weakened by 
over-frequent pregnancies, or by lactation during the early months of 
pregnancy. Indeed, anaemia is always well marked in this disease. 
Mental conditions also are frequently traceable in connection with its 
production. Morbid dread during pregnancy, insufficient to produce 
insanity before delivery, may develop into mental derangement after it. 
Shame and fear of exposure in unmarried women not unfrequently lead 
to it, as is evidenced by the fact that out of 2281 cases, gathered from 
the reports of various asylums, above 64 per cent, were unmarried. 1 
Sudden moral shocks or vivid mental impressions may be the determin- 
ing cause in predisposed persons. Gooch narrates an example of this 
in a lady who was attacked immediately after a fright produced by a 
fire close to her house, the hallucinations in this case being all connected 
with light ; and Tyler Smith, that of another whose illness dated from 
the sudden death of a relative. The age of the patient has some influ- 
ence, and there seems to be a decidedly greater liability at advanced 
ages, especially when such women are pregnant for the first time. 

Theory of its Dependence on a Morbid State of the Blood. — The possi- 
bility of the acute form of puerperal insanity, coming on shortly after 
delivery, being dependent on some form of septicaemia is one which 
deserves careful consideration. The idea originated with Sir James 
Simpson, who found albumen in the urine of four patients. He sug- 
gested that this might properly indicate the presence in the blood of cer- 
tain urinary constituents which might have determined the attack, much 
in the same way as in eclampsia. Dr. Donkin subsequently wrote an 
important paper, 2 in which he warmly supported this theory, and 
arrived at the conclusion " that the acute dangerous class of cases are 
examples of ursemic blood-poisoning, of which the mania, rapid pulse, 
and other constitutional symptoms are merely the phenomena ; and that 
the affection, therefore, ought to be termed ursemic or renal puerperal 
mania in contradistinction to the other form of the disease." He also 
suggests that the immediate poison may be carbonate of ammonia, 
resulting from the decomposition of urea retained in the blood. It will 
be observed, therefore, that the pathological condition producing puer- 
peral mania would, supposing this theory to be correct, be precisely the 
same as that which at other times is supposed to give rise to puerperal 
eclampsia. There can be no doubt that the patient immediately after 
delivery is in a condition rendering her peculiarly liable to various 
forms of septic disease ; and it must be admitted that there is no inher- 
ent improbability in the supposition that some morbid material circulat- 
ing in the blood may be the effective cause of the attack in a person 
1 Journ. of Mental Science, 1870-71, p. 159. 2 Edin. Med. Jovrn., vol. vii. 



PUERPERAL INSANITY. 587 

otherwise predisposed to it. It is also certain, as I have already pointed 
out, that there are two distinct classes of cases, differing according to the 
period after delivery at which the attack comes on. Whether this dif- 
ference depends on the presence in the blood of some septic matter — 
especially urinary excreta — is a question which our knowledge by no 
means justifies us in answering; it is, however, one which well merits 
further careful study. 

Objections to this Theory. — It is only fair to point out some difficul- 
ties which appear to militate against the view which Dr. Donkin main- 
tains. In the first place, the albuminuria is merely transient, while its 
supposed effects last for weeks or months. Sir James Simpson says, 
with regard to his cases, " I have seen all traces of albuminuria in puer- 
peral insanity disappear from the urine within fifty hours of the access 
of the malady. The general rapidity of its disappearance is perhaps the 
principal — or indeed the only — reason why this complication has escaped 
the notice of those physicians among us who devote themselves with 
such ardor and zeal to the treatment of insanity in our public asylum-/' 
This apparent anomaly Simpson attempts to explain by' the hypothesis 
that when once the ursemic poisoning has done its work and set the dis- 
ease in progress, the mania progresses of itself. This, however, is pure 
speculation, and in the supposed analogous case of eclampsia the albu- 
minuria certainly lasts as long as its effects. It is not easy to under- 
stand, also, why ursemic poisoning should in one case give rise to insan- 
ity and in another to convulsions. For all we know to the contrary, 
transient albuminuria may be much more common after delivery than 
has been generally supposed, and further investigation on this point is 
required. Albumen is by no means unfrequently observed in the urine, 
for a short time, in various conditions of the body, without any serious 
consequences, as, for example, after bathing; and we may too readily 
draw an unjustifiable conclusion from its detection in a few cases of 
mania. There are, however, many other kinds of blood-poisoning 
besides uraemia which may have an influence in the production of the 
disease, and it is to be hoped that future observations may enable US to 
speak with more certainty on this poiut. 

Prognosis, — The prognosis of puerperal insanity is a point which will 
always deeply interest those who have to deal with so distressing a 
malady. It may resolve itself into a consideration of the Immediate 
risk to life and of the chances of ultimate restoration of the mental fac- 
ulties. It is an old aphorism of Gooch'i — and one the correctness of 
which is justified by modern experiena — thai "mania i- more danger- 
ous to life, melancholia to reason." It has very generally been supposed 

that the immediate risk to life in puerperal mania i- not greal : and "ii 
the whole this may be taken as correct. Tllke found that death took 

place, from all causes, in 1<>.<) per cent, of the cases under observation ; 
these, however, were all women who had been admitted Into asylums, 
and in whom the attack may l>e assumed to have been exceptionally 
severe. Great stress was laid by Hunter and Gooch on extreme rapid- 
ity of the pulse as Indicating a fatal tendency. There can !><■ no doubt 
that it is a symptom of greal gravity, but by no means one which need 
lead us to despair of our patient'- recovery. The most dangerous class 



588 THE PUEBPEEAL STATE. 

of cases are those attended with some inflammatory complication ; and 
if there be marked elevation of temperature, indicating the presence of 
some such concomitant state, our prognosis must be more grave than 
when there is mere excitement of the circulation. 

Post-mortem Signs.- — There are no marked post-mortem signs found 
in fatal cases to guide us in forming an opinion as to the nature of the 
disease. " No constant morbid changes/' says Tyler Smith, " are found 
within the head, and most frequently the only condition found in the 
brain is that of unusual paleness and exsanguinity. Many pathologists 
have also remarked upon the extremely empty condition of the blood- 
vessels, particularly the veins." 

Duration of the Disease. — The duration of the disease varies consider- 
ably. Generally speaking, cases of mania do not last so long as melan T 
cholia, and recovery takes place within a period of three months, often 
earlier. Very few of the cases admitted into the Edinburgh Asylum 
remained there more than six months, and after that time the chances 
of ultimate recovery greatly lessened. When the patient gets well, it 
often happens that her recollection of the events occurring during her 
illness is lost ; at other times the delusions from which she suffered 
remain ; as, for example, in a case which was under my care in Avhich 
the personal antipathies which the patient formed when insane became 
permanently established. 

Insanity of Lactation. — 54 out of the 155 cases collected by Dr. Tuke 
were examples of the insanity of lactation, which would appear, there- 
fore, to be nearly twice as common as that of pregnancy, but consider- 
ably less so than the true puerperal form. Its dependence on causes 
producing anaemia and exhaustion is obvious and well marked. In the 
large majority of cases it occurs in multipara who have been debilitated 
by frequent pregnancies and by length of nursing. When occurring in 
primaparse, it is generally in women who have suffered from post-partum 
hemorrhage or other causes of exhaustion, or whose constitution was such 
as should have contraindicatecl any attempt at lactation. The bruit de 
diable is almost invariably present in the veins of the neck, indicating 
the impoverished condition of the blood. 

The type is far more frequently melancholic than maniacal, and when 
the latter form occurs the attack is much more transient than in true 
puerperal insanity. The danger to life is not great, especially if the 
cause producing debility be recognized and at once removed. 

There seems, however, to be more risk of the insanity becoming per- 
manent than in the other forms. In 12 out of Dr. Tuke's cases the mel- 
ancholia degenerated into dementia, and the patients became hopelessly 
insane. 

Symptoms. — The symptoms of these various forms of insanity are 
practically the same as in the non-pregnant state. 

In Cases of Mania. — Generally, in cases of mania there is more or 
less premonitory indication of mental disturbance, which may pass un- 
perceived. The attack is often preceded by restlessness and loss of sleep, 
the latter being a very common and well-marked symptom, or, if the 
patient sleep, her rest is broken and disturbed by dreams. Causeless 
dislikes to those around her are often observed : the nurse, the husband, 



PUERPERAL INSANITY. 589 

the doctor, or the child becomes the object of suspicion, and, unless 
proper care be taken, the child may be seriously injured. A- the dis- 
ease advances the patient becomes incoherent and rambling in her talk, 
and in a fully-developed case she is incessantly pouring forth an uncon- 
nected jumble of sentences out of which no meaning can be made. ( >ften 
some prevalent idea which is dwelling in the patient's mind can be traced 
running through her ravings, and it has been noticed that this is fre- 
quently of a sexual character, causing women of unblemished reputation 
to use obscene and disgusting language which it is difficult to under- 
stand their even having heard. The tendency of such patients to make 
accusations impugning their own chastity was specially insisted on by 
many eminent authorities in a recent celebrated trial, when Sir James 
Simpson stated that in his experience "the organ diseased gave a type 
to the insanity, so that with women suffering from affections of the geni- 
tal organs the delusions would be more likely to be connected with sexual 
matters." Religious delusions — as a fear of eternal damnation or of 
having committed some unpardonable sin — are of frequent occurrence, 
but perhaps more often in cases which are tending to the melancholic type. 
There is generally intolerable restlessness, and the patient's whole man- 
ner and appearance are those of excessive excitement. She may refuse 
to remain in bed, may tear off her clothes, or may attempt to injure 
herself. The suicidal tendency is often very marked. In one case under 
my care the patient made incessant efforts to destroy herself, which were 
onlv frustrated by the most careful watching ; she endeavored to strangle 
herself with the bedclothes, to swallow any article she could lay hold of, 
and even to gouge out her own eyes. Food is generally persistently re- 
fused, and the utmost coaxing may fail in inducing the patient to take 
nourishment. The pulse is rapid and small, and the more violent the 
excitement and furious the delirium the more excited is the circulation. 
The tongue is coated and furred, the bowels constipated and disordered, 
and the feces, as well as the urine, are frequently passed involuntarily. 
The urine is scanty and high-colored, and after the disease ha- la-ted for 
some time it becomes loaded with phosphates. The Lochia and the g 
tion of milk generally become arrested at (he commencement of the dis- 
ease. The waste of tissue, from the incessant restlessness and movement 

of the patient, is very great, and if the disease continue for BOme time 
she fall- into a condition of marasmus, which may be so excessive that 

-he becomes wasted to a -hadow of her former -i/e. 

Symptoms of Melancholia. — When the insanity assumes the form of 
melancholia its advent i- more gradual. It may commence with depres- 
sion of spirits without any adequate cause, associated with insomnia, dis- 
turbed digestion, headache, and other indications of bodily derangement 
Such symptoms, showing themselves in women who have been nursing 
for a length of time or in whom any other evident cause of exhaustion 
exists, should never pass unnoticed. Soon the signs of mental d< 
sion increase and positive delusions show themselves. These may varj 

much in their amount, but they are all more Or less of the Same type, 

and very often of a religious character. The .■ unl of constitutional 

disturbance varies much. In some cases which approach in character 
those of mania there is <•on-i.kral.le excitement, rapid pulse, furred 



590 THE PUERPERAL STATE. 

tongue, and restlessness. Probably cases of acute melancholia coming 
on during the puerperal state most often assume this form. In others, 
again, there is less of these general symptoms ; the patieuts are pro- 
foundly dejected, sit for hours without speaking or moving ; but there 
is not much excitement, and this is the form most generally characteriz- 
ing the insanity of lactation. In all cases there is a marked disinclina- 
tion to food. There is also, almost invariably, a disposition to suicide ; 
and it should never be forgotten in melancholic cases that this may de- 
velop itself in an instant, and that a moment's carelessness on the part 
of the attendants may lead to disastrous results. 

Treatment. — Bearing in mind what has been said of the essential cha- 
racter of puerperal insanity, it is obvious that the course of treatment 
must be mainly directed to maintain the strength of the patient, so as to 
enable her to pass through the disease without fatal exhaustion of the 
vital powers, while we endeavor at the same time to calm the excitement 
and give rest to the disturbed brain. Any over-active measures — for 
example, bleeding, blistering the shaven scalp, and the like — are dis- 
tinctly contrairidicated. 

There is a general agreement on the part of alienist physicians that in 
cases of acute mania the two things most needed are a sufficient quantity 
of suitable food and sleep. 

Importance of Administering Nourishment. — Every endeavor should 
be made to induce the patient to take plenty of nourishment, to remedy 
the defects of the excessive waste of tissue and support her strength 
until the disease abates. Dr. Blandford, who has especially insisted on 
the importance of this, says: 1 "Now, with regard to the food, skilful 
attendants will coax a patient into taking a large quantity, and we can 
hardly give too much. Messes of minced meat with potato and greens, 
diluted with beef-tea, bread and milk, rum and milk, arrowroot, and so 
on, may be got down. Never give mere liquids so long as you can get 
down solids. As the malady progresses the tongue and mouth may 
become so dry and foul that nothing but liquids can be swallowed ; but, 
reserving our beef-tea and brandy, let us give plenty of solid food while 
we can." 

Forcible Administration of Food. — The patient may in mania, as well 
as in melancholia — perhaps even more in the latter — obstinately refuse 
to take nourishment at all, and we may be compelled to use force. Vari- 
ous contrivances have been employed for this purpose. One of the sim- 
plest is introducing a dessert-spoon forcibly between the teeth, the patient 
being controlled by an adequate number of attendants, and slowly inject- 
ing into the mouth suitable nourishment by an india-rubber bottle with 
an ivory nozzle, such as is sold by all chemists. Care must be taken 
not to inject more than an ounce at a time, and to allow the patient to 
breathe between each deglutition. So extreme a measure will seldom 
be required if the patient have experienced attendants who can over- 
come her resistance to food by gentler means ; but it may be essential, 
and it is far better to employ it than to allow the patient to become ex- 
hausted from want of nourishment. In one case I had to feed a patient 
in this way three times a day for several weeks, and used for the pur- 

1 Blandford, Insanity and its Treatment 



PUERPERAL INSANITY. 591 

pose a contrivance known in asylums as Paley's feeding-bottle, which 
reduced the difficulty of the process to a minimum. Beef-tea or strong 
soup mixed with some farinaceous material, such as Revalenta Arabica, 
or wheaten flour or milk, forms the best mess for this purpose 

Stimulants. — In the early stages the patient is probably better without 
stimulants, which seem only to increase the excitement. As the disease 
progresses and exhaustion becomes marked, it may be necessary to have 
recourse to them. In melancholia they seem to be more useful, and may 
be administered with greater freedom. 

State of the Bowels. — The state of the bowels requires especial atten- 
tion. They are almost always disordered, the evacuations being dark 
and offensive in odor. In the early stages of the disease the prompt 
clearing of the bowels by a suitable purgative sometimes has the effect 
of cutting short an impending attack. A curious example of this is 
recorded by Gooch, in which the patient's recovery seemed to date from 
the free evacuation of the bowels. A few grains of calomel or a dose 
of compound jalap powder or of castor oil may generally be readily 
given. During the continuance of the illness the state of the prima vise 
should be attended to, and occasional aperients will be useful, but strong 
and repeated purgation is hurtful, from the debility it produce-. 

The Procuring Sleep. — The procuring sleep will necessarily form one 
of the most important points of treatment. For this purpose there is 
no drug; so valuable as the hvdrate of chloral, either alone or in com- 
bination with bromide of potassium, which has a distinct effect in increas- 
ing its hypnotic action. Given in a full dose at bedtime — say 1 5 grs. 
to 3ss — it rarely fails in procuring at least some sleep, and in an early 
stage of acute mania this may be followed by the best effects. It may 
be necessary to repeat this draught night after night during the acute 
stage of the malady. If we cannot induce the patient to -wallow the 
medicine, it may be given in the form of enema. 

Question of Administering Opiate*. — It is generally admitted thai in 
mania preparations of opium, formerly much relied on in the treatment 
of the disease, are apt to do more harm than good. Dr. Blandford gives 
a strong opinion on this point. He says: "In prolonged delirious 
mania I believe opium never does good, and may do great harm, W e 
shall see the effects of narcotic poisoning if it be pushed, but none that 
are beneficial. This applies equally to opium given by the mouth and 
by subcutaneous injection. The latter, as it is more certain and effectual 
in producing good results, is also more deadly when it acts as b narcotic 
poison. Alter the administration of a doseof morphia by the subcu- 
taneous method the patient will probably at once fall asleep, and w 
gratulafc ourselves that our long-wished-fbr object is attained. But 
after half an hour or so the sleep suddenly terminates, and the mania 
and excitement are worse than before. Here you may possibly think 
that, had the dose been larger, instead of half an hour's sleep you would 
have obtained one of longer duration ; and you may administer more, 
but with a like result Lai-- .1—- of morphia not merely foil t.> pro- 
duce refreshing sleep \ they poison the patient, and produce, if not the 
symptom- of actual narcotic poisoning, at any rate that typhoid condi- 
tion which indicate- prostration and approaching collapse. 1 believe 



592 THE PUERPERAL STATE. 

there is no drug the use of which more often becomes abused than that 
of opium." It is otherwise in cases of melancholia, especially in the 
more chronic forms. In these opiates, in moderate doses, not pushed to 
excess, may be given with great advantage. The subcutaneous injection 
of morphia is by far the best means of exhibiting the drug, from its 
rapidity of action and facility of administration. 

Other Calmatives. — There are other methods of calming: the excite- 
ment of the patient besides the use of medicines. The prolonged use 
of the warm bath, the patient being immersed in water at a temperature 
of 90° or 92° for at least half an hour, is highly recommended by some 
as a sedative. The wet pack serves the same purpose, and is more 
readily applied in refractory subjects. 

Importance of Judicious Nursing. — Judicious nursing is of primary 
importance. The patient should be kept in a cool, well-ventilated, and 
somewhat darkened room. If possible she should remain in bed, or at 
least endeavors should be made to restrain the excessive restless motion 
which has so much effect in promoting exhaustion. The presence of 
relatives and friends, especially the husband, has generally a prejudicial 
and exciting effect ; and it is advisable to place the patient under the 
care of nurses experienced in the management of the insane, who, as 
strangers, are likely to have more control over her. It is not too much 
to say that much of the success in treatment must depend on the manner 
in which this indication is met. Rough, unskilled nurses, who do not 
know how to use gentleness combined with firmness, will certainly 
aggravate and prolong the disorder. Inasmuch as no patient should be. 
left un watched by day or night, more than one nurse is essential. 

Question of Removal to an Asylum. — The question of the removal of 
the patient to an asylum is one which will give rise to anxious considera- 
tion. As the fact of having been under such restraint of necessity fixes 
a certain lasting stigma upon a patient, this is a step which every one 
would wish to avoid if possible. In cases of acute mania, which will 
probably last a comparatively short time, home-treatment can generally 
be efficiently carried out. Much must depend on the circumstances of 
the patient. If these be of a nature which preclude the possibility of 
her obtaining thoroughly efficient nursing and treatment in her own 
home, it is advisable to remove her to a place where these essentials can 
be obtained, even at the cost of some subsequent annoyance. In cases 
of chronic melancholia, the management of which is on the whole more 
difficult, the necessity for such a measure is more likely to arise, and 
should not be postponed too late. Many examples of incurable demen- 
tia arising out of puerperal melancholia can be traced to unnecessary 
delay in placing the patients under the most favorable conditions for 
recovery. 

Treatment during Convalescence. — When convalescence is commencing, 
change of air and scene will often be found of great value. Removal 
to some quiet country place, where the patient can enjoy abundance of 
air and exercise in the company of her nurses, without the excitement 
of seeing many people, is especially to be recommended. Great caution 
must be used in admitting the visits of relatives and friends. In two 
cases under my own care the patients relapsed, when apparently pro- 



PUERPERAL SEPTICEMIA. 593 

gressing favorably, because the husbands insisted, contrary to advice, od 
seeing them. On the other hand, Gooch has pointed out that when the 
patient is not recovering, when month after month has been passed in 
seclusion without any improvement, the visit of a friend or relative may 
produce a favorable moral impression and inaugurate a change for the 
better. It is probably in cases of melancholia, rather than in mania, 
that this is likely to happen. The experiment may under such circum- 
stances be worth trvins;, but it is one the result of which we must con- 
template with some anxiety. 



CHAPTER Y. 

PUERPERAL SEPTICEMIA. 



Difference of Opinion as to Puerperal Fever. — There is no subject in 
the whole range of obstetrics which has caused so much discussion and 
difference of opinion as that to which this chapter is devoted. Under 
the name of Puerperal Fever the disease we have to consider has given 
rise to endless controversy. One writer after another has stated bis 
view of the nature of the affection with dogmatic precision, often on no 
other grounds than his own preconceived notions and an erroneous inter- 
pretation of some of the post-mortem appearances. Thus, one .-tap- 
that puerperal fever is only a local inflammation, such as peritonitis; 
others declare it to be phlebitis, metritis, metro-peritonitis, or an essen- 
tial zymotic disease, sui generis, which affects lying-in women only. The 
result has been a hopeless confusion, and the student rises from the 
Study of the subject with little more useful knowledge than when he 
began. Fortunately, modern research is beginning to throw a little 
light upon tin- chaos. 

Modern View of the Disease. — The whole tendency of recent investi- 
gation is daily rendering it more and more certain that obstetricians have 
been led into error by the special virulence and intensity of the disease, 
and that they have erroneously considered it to be something special to 
the puerperal state, instead of recognizing in it a form of septic disease 
practically identical with that which i- iamiliar to surgeons under the 
name of pyaemia or septicaemia. 

Objection to the Name " Puerperal Fever" — [f this view be correct, 
the term "puerperal lexer," conveying the ideaofa fever such as typhus 
or typhoid, musi be acknowledged to be misleading, and one that should 
!),• discarded a- only tending to confusion. Before discussing at l< 
the reasons which render it probable that the disease i- in no wai spe- 
cific or peculiar to the puerperal state, it will be well to relate briefly 

some oi" the leading facts connected with \\. 

History of the Disease. — More or Less distinct references t-> the exist- 
ence of the so-called puerperal fever arc m< t with in the classical authors, 

38 



594 THE PUERPERAL STATE. 

proving, beyond doubt, that the disease was well known to them ; and 
Hippocrates, besides relating several cases the nature of which is unques- 
tionable, clearly recognizes the possibility of its originating in the reten- 
tion and decomposition of portions of the placenta. Although Harvey 
and other writers showed that they were more or less familiar with it, 
and even made most creditable observations on its etiology, it was not 
until the latter half of the last century that it came prominently into 
notice. At that time the frightful mortality occurring in some of the 
principal lying-in hospitals, especially in the Hotel Dieu at Paris, 
attracted attention ; and ever since the disease has been familiar to 
obstetricians. 

Mortality resulting from it in Lying-in Hospitals. — Its prevalence in 
hospitals in which lying-in women are congregated has been constantly 
observed both in this country and abroad, occasionally producing an 
appalling death-rate ; the disease, when once it has appeared, frequently 
spreading from one patient to another in spite of all that could be done 
to arrest it. It would be easy to give many startling instances of this. 
Thus, it prevailed in London in the years 1760, 1768, and 1770 to such 
an extent that in some lying-in institutions nearly all the patients died. 
Of the Edinburgh Infirmary in 1773 it is stated that " almost every 
woman as soon as she was delivered, or perhaps about twenty-four hours 
after, was seized with it, and all of them died, though every method was 
used to cure the disorder." On the Continent, where the lying-in insti- 
tutions are on a much larger scale, the mortality was equally great. 
Thus in the Maison d'Accouchements of Paris in a number of different 
years sometimes as many as 1 in 3 of the women delivered died, on one 
occasion 10 women dying out of 15 delivered. Similar results were ob- 
served in other great continental hospitals, as in Vienna, where, in 1823, 
19 per cent, of the cases died, and, in 1842, 16 per cent. ; and in Berlin 
in 1862 hardly a single patient escaped, the hospital being eventually 
closed. 

Should Lying-in Hospitals be Abolished f — Such facts, the correctness 
of which is beyond any question, prove to demonstration the great risk 
which may accompany the aggregation of lying-in women. Whether 
they justify the conclusion that all lying-in hospitals should be abolished 
is another and a very wide question which can scarcely be satisfactorily 
discussed in a practical work. It is to be observed, however, that most 
of the cases in which the disease produced such disastrous results oc- 
curred before our more recent knowledge of its mode of propagation was 
acquired, when no sufficient hygienic precautions were adopted, when 
ventilation was little thought of, and when, in a word, every condition 
prevailed that would tend to favor the spread of a contagious disease 
from one patient to another. More recent experience proves that when 
the contrary is the case (as, for example, in such an institution as the 
Rotunda Hospital in Dublin), the occurrence of epidemics of this kind 
may be entirely prevented and the mortality approximated to that of 
home-practice. 

The Assumption of a Puerperal Miasm is Unnecessary. — The more 
closely the history of these outbreaks in hospitals is studied, the more 
apparent does it become that they are not dependent on any miasm 



PUERPERAL SEPTICEMIA. 595 

necessarily produced by the aggregation of puerperal patients, but on the 
direct conveyance of septic matter from one patient to another. 

In numerous instances the disease has been said to be generally epi- 
demic in domiciliary practice, much in the same way as scarlet fever or 
any zymotic complaint might be. Such epidemics are described as hav- 
ing occurred in London in 1827— 28, in Leeds in 1809-12, in Edinburgh 
in 1825, and many others might be cited. There is, however, do suffi- 
cient ground for believing that the disease has ever been epidemic in the 
strict sense of the word. That numerous cases have often occurred in 
the same place and at the same time is beyond question ; but this can 
easily be explained without admitting an epidemic influence, knowing as 
we do how readily septic matter may be conveyed from one patient to 
another. In many of the so-called epidemics the disease has been lim- 
ited to the patients of certain mid wives or practitioners, while those of 
others have entirely escaped — a fact easily understood on the assumption 
of the disease being produced by septic matter conveyed to the patient, 
but irreconcilable with the view of general epidemic influence. We are 
not in possession of any reliable statistics of the mortality arising from 
puerperal septicaemia in ordinary general practice. It has, however, 
been well pointed out, in the Report on Puerperal Fever presented by 
the Obstetrical Society of Berlin to the Prussian Minister of Health, 1 
that not only do the published returns of death from metria afford DO 
reliable estimate of the actual mortality from this source, but that they 
are very far more numerous than deaths from any other cause in con- 
nection with pregnancy and childbirth. 

Numerous Theories advanced regarding its Nature. — It would be a 
useless task to detail at length the theories that have been advanced to 
explain the disease. Indeed, it may safely be held that the supposed 
necessity of providing a theory which would explain all the facts of the 
disease has done more to surround it with obscurity than even the diffi- 
culties of the subject itself. If any .real advance is to be made, it can 
only be by adopting a humble attitude, by admitting that we are only on 
the threshold of the inquiry, and by a careful observation of clinical 
facts, without drawing from them too positive deductions. 

Theory of /As Local Origin. — Many have taught that the disease 
is essentially a local inflammation producing secondary constitutional 

effects. This view doubtless originated from t exclusive attention t<> 

the morbid changes found on post-mortem examination. Excessive 
peritonitis, phlebitis, inflammation of the Lymphatics or of the tissues 
of the uterus, are very commonly found after death ; and each of these 
has, in it.^ turn, been believed to be the real source of Hi- disease. I his 
view finds but little favor with modern pathologists, and i~ in so many 
ways inconsistent with clinical facts that it may be considered t" be 
obsolete. No one of the condition- above mentioned is universally 
found, and in the worst cases definite signs <>f local inflammation may 
be entirely absent. Nor will this theory explain the conveyance of the 
disease from one patient to another, or the peculiar severity oi the con- 
stitutional symptoms. 

Theory of <m Essential Zymotic Fever. — A more admissible theory, 

1 Bee Edin. Med. Journ.. N 



596 THE PUERPERAL STATE. 

and one which has been extensively entertained, is, that there is an 
essential zymotic fever peculiar to, and only attacking, puerperal women, 
which is as specific in its nature as typhus or typhoid, and to which the 
local phenomena observed after death bear the same relation that the 
pustules on the skin do to small-pox or the ulcers in the intestinal 
glands to typhoid. This fever is supposed to spread by contagion and 
infection, and to prevail epidemically, both in private and in hospital 
practice. The most recent exponent of this view is Fordyce Barker, 
who in his excellent work on the Puerperal Diseases has entered at 
length into all the theories of the disease. He, like others who hold his 
opinions, has, I cannot but think, entirely failed to bring forward any 
conclusive evidence of the existence of such a specific fever. It is no 
doubt true that in typhus and typhoid and other undoubted examples 
of this class of disease there are well-marked local secondary phenomena ; 
but then they are distinct and constant. He makes no attempt to prove 
that anything of the kind occurs in puerperal fever. On the contrary, 
probably there are no two cases in which similar local phenomena occur, 
nor is there any case in which the most practised obstetrician could fore- 
tell either the course and duration of the illness or the local phenomenon. 
Again, this theory altogether fails to explain the very important class of 
cases which can be distinctly traced to sources originating in the patient 
herself — viz. the absorption of septic matter from decomposing coagula 
and the like. Barker meets this difficulty by placing such cases of auto- 
infection under a separate category, admitting that they are examples of 
septicaemia. But he fails to show that there is any difference in symp- 
tomatology or post-mortem signs between them and the cases he believes 
to depend on an essential fever ; nor would it be possible to distinguish 
the one from the other by either their clinical or pathological history. 

Theory of its Identity with Surgical Septiccemia. — The modern view, 
w T hich holds that the disease is, in fact, identical with the condition 
known as pyaemia or septicaemia, is by no means free from objections, 
and much patient clinical investigation is required to give a satisfactory 
explanation of certain peculiarities which the disease presents ; but in 
spite of these difficulties, which time may serve to remove, it offers a far 
better explanation of the phenomena observed than any other that has 
yet been advanced. 

According to this theory, the so-called puerperal fever is produced by 
the absorption of septic matter into the system through solutions of con- 
tinuity in the generative tract, such as always exist after labor. It is not 
essential that the poison should be peculiar or specific, for, just as in sur- 
gical pyaemia, any decomposing organic matter, either originating w r ithin 
the generative organs of the patient herself or coming from without, may 
set up the morbid action. 

In describing the disease under discussion I shall assume that, so far 
as our present knowledge goes, this view is the one most consonant with 
facts ; but, bearing in mind that very little is yet known of surgical 
septicaemia, it must not be expected that obstetricians can satisfactorily 
explain all the phenomena they observe. 

Basis of Description. — The best basis of description I know of is that 
given by Burdon Sanderson when he says, " In every pyaemic process 



PUERPERAL SEPTICEMIA. 597 

you may trace a focus, a centre of origin, lines of diffusion or distribu- 
tion, and secondary results from the distribution — in every case an 
initial process from which infection commences, from which the infection 
spreads, and secondary processes which come out of this primary one." 1 
Adopting this division, I shall first treat of the mode in which the 
infection may commence in obstetric cases, and point out the special dif- 
ficulties which this part of the subject presents. 

Channels through which Septic Matter may be Absorbed. — The fact 
that all recently-delivered women present lesions of continuity in the 
generative tract, through which septic matter, brought into contact with 
them, may be readily absorbed, has long been recognized. The analogy 
between the interior of the uterus after delivery and the surface of a 
stump after amputation was particularly insisted on by Cruveilhier, 
Simpson, and others — an analogy which was, to a great extent, based on 
erroneous conceptions of what took place, since they conceived that the 
whole interior of the uterus was bared. It is now well known that that 
is not the case ; but the fact remains that at the placental site, at any 
rate, there are open vessels through which absorption may readily take 
place. That absorption of septic material occurs through this channel is 
probable in certain cases in which decomposing materials exist in the 
interior of the uterus, especially when, from defective uterine contrac- 
tion, the venous sinuses are abnormally patulous and are not occluded 
by thrombi. It is difficult to understand how septic matter, introduced 
from without, can reach the placental site. Other sites of absorption 
are, however, always available. These exist in every case in the form 
of slight abrasions or lacerations about the cervix, or in the vagina, or, 
especially in primiparae, about the fourchette and perineum. There is 
even some reason to think that absorption of septic matter may take 
place through the mucous membrane of the vagina or cervix without 
any breach of surface. This might serve to account for the occasioual 
although rare eases in which symptom- of the disease develop themselves 
before delivery, or so soon after it as to show that the infection musl 
have preceded labor; nor is there any inherent improbability in the -lip- 
position that septic material may be occasionally absorbed through the 
unbroken mucous membrane, as is certainly the case with some poisons — 
for example, that of syphilis. Eence there is no difficulty in recognizing 
the similarity of a lying-in woman to a patient suffering from ;i recent 
surgical lesion, or in understanding how septic matter conveyed to her 
during or shortly after labor may be absorbed. Ii is necessary, how- 
ever, to suppose that absorption take- place immediately or very shortly 
after these lesions of continuity are formed, i'm ii is well knom n thai the 
power of absorption i- arrested after they have commenced t<> heal. 
This fact may explain the cases in which sloughing aboul the perineum 
or vagina exists without any septicaemia resulting, or the fir Prom un- 
common cases in which ;m intensely fetid lochia! discharge may be pres- 
ent a few days after delivery without any infection taking place. 

The character and sources of the septic matter constitute one of the 
most obscure questions in connection with septicaemia, and that which is 
most open t<> discussion. 

1 Clinical '!•<< foi. yiii. p. 108. 



598 THE PUERPERAL STATE. 

Division into Autogenetic and Heterogenetic Cases. — The most practi- 
cal division of the subject is into cases in which the septic matter origi- 
nates within the patient, so that she infects herself, the disease then being 
properly autogenetic ; and into those in which the septic matter is con- 
veyed from without, and brought into contact with absorptive surfaces 
in the generative tract, the disease then being heterogenetic. 

Sources of Self-infection. — The sources of auto-infection may be vari- 
ous, but they are not difficult to understand. Any condition giving rise 
to decomposition, either of the tissues of the mother herself, of matters 
retained in the uterus or vagina that ought to have been expelled, or 
decomposing matter derived from a putrid foetus, may start the septice- 
mic process. Thus it may happen that from continuous pressure on the 
maternal soft parts during labor sloughing has set in, or there may be 
already decomposing material present from' some previous morbid state of 
the genital tracts, as in carcinoma. A more common origin is the retention 
of coagula or of small portions of membrane or of placenta in the interior 
of the uterus, which have putrefied from access of air, or in the decom- 
position of the lochia. That the retention of portions of the placental 
tissue has at all times been the cause of septicaemia may be illustrated by 
the case of the Duchesse d'Orleans (in the time of Louis XIII. ), who 
had an easy labor, but died of childbed fever. An examination was 
made by the leading physicians of Paris, in their report of which it was 
stated : " On the right side of the womb was found a small portion of 
after-birth so firmly adherent that it could be hardly torn off by the 
finger-nails." 1 The reason why self-infection does not more often occur 
from such sources, since more or less decomposition is of necessity so 
often present, has already been referred to in the fact that absorption of 
such matters is not apt to occur when the lesions of continuity always 
existing after parturition have commenced to heal. This observation 
may also serve to explain how previous bad states of health, by inter- 
fering with the healthy reparative process occurring after delivery, may 
predispose to self-infection. It is interesting to note that puerperal sep- 
ticaemia arising from such sources is not limited to the human race. In 
the debate on pyaemia at the Clinical Society, Mr. Hutchinson recorded 
several well-marked examples occurring in ewes, in whose uteri portions 
of retained placenta were found. 

Sources of Heterogenetic Infection. — The sources of septic matter con- 
veyed from without are much more difficult to trace, and there are many 
facts connected with heterogenetic infection Avhich are very difficult to 
reconcile with theory, and of which, it must be admitted, we are not yet 
able to give a satisfactory explanation. 

It is probable that any decomposing organic matter may infect, but 
that some forms operate with more certainty and greater virulence than 
others. 

Influence of Cadaveric Poisoning. — One of these, which has attracted 
special attention, is what may be termed cadaveric poison, derived 
from dissection of the dead subject in the anatomical and post-mortem 
theatres, and conveyed to the genital tract by the hands of the accou- 
cheur. Attention was particularly directed to this source of infection 

1 Louise Bourgeois, by Goodell. 



PUERPERAL SEPTICJSMIA. 599 

by the observations of Semmelweiss, who showed that in the division of 
the Vienna Lying-in Hospital attended by medical men and students 
who frequented the dissecting-rooms the mortality was seldom less than 
1 in 10, while in the division solely attended by women the mortality 
never exceeded 1 in 34; the number of deaths in the former division at 
once falling to that of the latter so soon as proper precautions and means 
of disinfection were used. Many other facts of a like nature have since 
been recorded which render this origin of puerperal septicaemia a matter 
of certainty. An interesting example is related by Simpson with cha- 
racteristic candor: "In 1836 or 1837, Mr. Sidey of this city had a rapid 
succession of five or six cases of puerperal fever in his practice at a time 
when the disease was not known to exist in the practice of any other 
practitioners in the locality. Dr. Simpson, who had then no firm or 
proper belief in the contagious propagation of puerperal fever, attended 
the dissection of Mr. Sidey's patients and freely handled the diseased 
parts. The next four cases of midwifery which Dr. Simpson attended 
were all affected with puerperal fever, and it was the first time lie had 
seen it in practice. Dr. Patterson of Leith examined the ovaries, etc. 
The three next cases which Dr. Patterson attended in that town were 
attacked with the disease/' 1 Negative examples are of course brought 
forward of those who have attended post-mortem examination- without 
injury to their obstetric patients, which merely prove that the cadaveric 
poison does not, of necessity, attach itself to the hands of the dissector; 
and no amount of such testimony can invalidate such positive evidence 
as that just narrated. Barnes believes that there is not so much danger 
attending the dissection of patients who have died of any ordinary dis- 
ease, but that the risk attending the dissection of those who have died 
of infectious or contagious complaint- is very great indeed. 2 I presume 
there is no doubt that the risk is greater when the subject ha- died from 
zymotic disease, but the distinction is too delicate to rely on ; and the 
attendant on midwifery will certainly err on the safe side by avoiding :i- 
much as possible having anything to do with the conduct of dissections 
or post-mortem examinations. 

Infection from Erysipelas. — Another possible source of infection is 
erysipelatous disease in all its forms. The intimate connection between 
erysipelas and surgical pyaemia has long been recognized by surgeons, 
and the influence of erysipelas in producing puerperal septicaemia has 
been especially observed in surgical hospitals inn> which lying-in 
patients were also admitted. Trousseau relates Instances "i" this Kind 

occurring in Pari-. The only instance thai I knom of in I Ion was 

in the lying-in ward of King's < lollege Hospital, w here, in -pin of e^ i rj 
hygienic precaution, the mortality wi- so greal as i<> necessitate Hi-' 
closure of the ward. Here the association of erysipelas with puerperal 
septicaemia was again and again observed, the latter proving fatal in 
direct proportion to the prevalence of the former in the Burgical wards. 
The dependence of the two on the same poison \\:i- in one instance curi- 
ously shown by the fad of the child of :i patient who died of puerperal 
septicaemia dying from erysipelas which started from a slight abi 

1 Selected ObsteL Works, p. 

1 '* Lectures on Puerperal !•■ ! E, vol. ii. l- 



600 THE PUERPERAL STATE. 

produced by the forceps. A more recent and very remarkable example 
is related by Dr. Lombe Atthill. 1 A patient suffering from erysipelas 
was admitted into the Rotunda Hospital on February 15, 1877. The 
sanitary condition of the hospital was at the time excellent. The 
patient was removed next day, but of the next 10 patients confined in 
adjoining wards, 9 were attacked with puerperal peritonitis, the only 
one who escaped being a case of abortion. But the connection between 
erysipelas and puerperal septicaemia is not limited to hospitals, having 
been often observed in domiciliary practice. Some interesting facts have 
been collected by Dr. Minor, 2 who has shown that the two diseases have 
frequently prevailed together in various parts of the United States, and 
that during a recent outbreak of puerperal fever in Cincinnati it occurred 
chiefly in the practice of those physicians who attended cases of erysipe- 
las. Many children also died from erysipelas whose mothers had died 
from puerperal fever. 

Infection from other Zymotic Diseases. — There is good reason to 
believe that the contagium of other zymotic diseases may produce a form 
of disease indistinguishable from ordinary puerperal septicaemia and pre- 
senting none of the characteristic features of the specific complaint from 
which the contagium was derived. This is admitted to be a fact by the 
majority of our most eminent British obstetricians, although it does not 
seem to be allowed by continental authorities, and it is strongly contro- 
verted by some writers in this country. It is certainly difficult to rec- 
oncile this with the theory of septicaemia, and we are not in a position 
to give a satisfactory explanation of it. I believe, however, that the 
evidence in favor of the possibility of puerperal septicaemia originating 
in this way is too strong to be assailable. 

Cases Produced by the Contagion of Scarlet Fever. — The scarlatinal 
poison is that regarding which the greatest number of observations have 
been made. Numerous cases of this kind are to be found scattered 
through our obstetric literature, but the largest number are to be met 
with in a paper by Dr. Braxton Hicks in the twelfth volume of the 
Obstetrical Transactions; and they are especially valuable from that 
gentleman's well-known accuracy as a clinical observer. Out of 68 
cases of puerperal disease seen in consultation, no less than 37 were dis- 
tinctly traced to the scarlatinal poison. Of these, 20 had the character- 
istic rash of the disease; but the remaining 17, although the history 
clearly proved exposure to the contagium of scarlet fever, showed none 
of its usual symptoms, and were not to be distinguished from ordinary 
typical cases of the so-called puerperal fever. On the theory that it is 
impossible for the specific contagious diseases to be modified by the 
puerperal state, we have to admit that one physician met with 17 cases 
of puerperal septicaemia in which, by a mere coincidence, the contagion 
of scarlet fever had been traced, and that the disease nevertheless origin- 
ated from some olher source — an hypothesis so improbable that its mere 
mention carries its own refutation. 

Cases Produced by the Contagion of other Zymotic Diseases. — With 
regard to the other zymotic diseases the evidence is not so strong, proba- 

1 Medical Press and Circular, April, 1877. 

2 Erysipelas and Childbed Fever, Cincinnati, 1874. 



PUERPERAL SEPTICAEMIA. 601 

bly from the comparative rarity of the diseases. Hicks mentions one 
case in which the diphtheritic poison was traced, although none of the 
usual phenomena of the disease were present. I lately saw a case in 
which a lady a few days after delivery had a very serious attack of sep- 
ticemia without any diphtheritic symptoms, her husband being at the 
same time attacked with diphtheria of a most marked type. Here it 
would be difficult not to admit the dependence of the two diseases on 
the same poison. 

The Zymotic Diseases are not always Modified in the Puerperal State. 
— It is, however, certain that all the zymotic diseases may attack a 
newly-delivered woman and run their characteristic course without any 
peculiar intensity. Probably most practitioners have seen cases of this 
kind; and this is precisely one of the points of difficulty which we can- 
not at present explain, but on which future research may be expected to 
throw some light. It seems to me not improbable that the explanation 
of the fact that zymotic poison may in one puerperal patient run its 
ordinary course, and in another produce symptoms of intense septicaemia, 
may be found in the channel of absorption. It is at any rate compre- 
hensible that if the contagium be absorbed through the skin or the 
ordinary channel it may produce its characteristic symptoms and run it- 
usual course, while if brought into contact with lesion- of continuity in 
the generative tract it may act more in the way of septic poison, or with 
such intensity that its specific symptoms arc not developed. 

It may reasonably be objected that if puerperal and surgical septicae- 
mia be identical the zymotic poisons ought to be similarly modified 
when they infect patients after surgical operations. The subject of 
specific contagium as a canst; of surgical pyaemia ha- been so little 
studied that I do not think any one would he justified in asserting that 
such an occurrence is not possible. Fritsch of Halle and other German 
physicians have recently shown how elaborate antiseptic precaution- in 
lying-in hospitals may prevent the origin of the disease from such 
sources. Sir .lame- Paget, in his Clinical Lectures, seems to believe in 
the possibility of such modification. He say s : " I think ii not improba- 
ble that in some cases results occurring with obscure Bvmptoms within 
two or three days after operations have been due to scarlet-fever poison, 
hindered in some way from it- usual progr< --." Sir Spencer Well- 
informs me that he ha- .-ecu cases of surgical pyaemia which he had rea- 
son to believe originated in the scarlatinal poison ; and hi- well-known 
success as an ovariotomisl is no doubt, in a great measure, to beattrib- 
uted to his extreme care in seeing that no one likely t<» come in contact 
with his patient- has been exposed t<> any such - ■ce of infection. 

Sewer (las <i, id Defective s<i,,ii<iri! Arrangements. — Exposure to sewer 
gas may, I feel sure, produce the disease. In two cases of the kind I 
had the opportunity of closely watching .-in untrapped drain opened 
directly into the bedroom — in one instance into a bain, in the other into 
a water-closet. Both cases were indistinguishable from the ordinan 

form of the disease, and in both improvement c menced >- the 

patient was removed into another room. 

In a case 1 saw some years ago in Notting Hill the patient, who had 
been confined within a week, had all the symptoms of a most intense 



602 THE PUERPERAL STATE. 

attack of septicaemia, bat none of a diphtheritic character, while her hus- 
band lay in an adjoining room suffering from a diphtheritic sore throat. 
Here the waste-pipe of the bath was found to communicate directly with 
the sewer. In spite of her intense illness, I had the patient removed to 
another house, and from that moment she began to improve. In two 
other cases in which the same source of disease was detected the removal 
of the patient from the infected atmosphere was immediately followed 
by a marked amelioration in the symptoms. I know of three similar 
cases which ended fatally in which I have every reason to believe 
that the cause of the disease was poisoning by sewer gas. Franken- 
hauser has related a curious case of the poisoning of four puerperal 
women by sewer gas. In fact, the whole question of defective sanitary 
conditions on the puerperal state deserves much more serious study than 
it has ever yet received, and I have long been satisfied that they have 
often much to do with certain grave forms of illness in the lying-in state 
the origin of which cannot otherwise be traced. 

Septicaemia from Contagion conveyed from other Puerperal Patients. — 
The last source from which septic matter may be conveyed is from a 
patient suffering from puerperal septicaemia — a mode of origin which 
has of late attracted special attention. That this is the explanation of 
the occasional endemic prevalence of the disease in lying-in hospitals can 
scarcely be doubted. The theory of a special puerperal miasm pervad- 
ing the hospital is not required to account for the facts, for there are a 
hundred ways impossible to detect or avoid — on the hands of nurses or 
attendants, in sponges, bed-pans, sheets, or even suspended in the atmo- 
sphere — in which septic material derived from one patient may be carried 
to another. 

The poison may be conveyed in the same manner from one private 
patient to another. Of this there are many lamentable instances re- 
corded. Thus it was mentioned by a gentleman at the recent discussion 
at the Obstetrical Society that 5 out of 14 women he attended died, no 
other practitioner in the neighborhood having a case. This origin of 
the disease was clearly pointed out by Gordon 1 toward the end of last 
century, who stated that he himself " was the means of carrying the 
infection to a great number of women ;" and he also traced the spread 
of the disease in the same way in the practice of- certain midwives. In 
some remarkable instances the unhappy property of carrying contagion 
has clung to individuals in a way which is most mysterious, and which 
has led to the supposition that the whole system becomes saturated with 
the poison. One of the strangest cases of this kind was that of Dr. 
Rutter of Philadelphia, which caused much discussion. He had 45 
cases of puerperal septicaemia in his own practice in one year, while none 
of his neighbors' patients were attacked. Of him it is related, " Dr. 
Rutter, to rid himself of the mysterious influence which seemed to 
attend upon his practice, left the city for ten days, and before waiting on 
the next parturient case had his hair shaved off and put on a wig, took 
a hot bath, and changed every article of his apparel, taking nothing 
with him that he had worn or carried to his knowledge on any former 
occasion ; and mark the result. The lady, notwithstanding that she had 

1 See Lectures on Puerperal Fever, by Robert J. Lee, M. D. 



PUERPERAL SEPTICEMIA. 603 

an easy parturition, was seized the next day with childbed fever, and 
died on the eleventh day after the birth of the child. Two years later 
he made another attempt at self-purification, and the next case attended 
fell a victim to the same disease." No wonder that Meigs, in comment- 
ing on such a history, refused to believe that the doctor carried the poi- 
son, and rather thought that he was " merely unhappy in meeting with 
such accidents through God's providence." It appears, however, that 
Dr. Rutter was the subject of a form of ozsena, and it is quite obvious 
that under such circumstances his hands could never have been five from 
septic matter. 1 This observation is of peculiar interest, as showing that 
the sources of infection may exist in conditions difficult to suspect and 
impossible to obviate, and it affords a satisfactory explanation of a ease 
which was for years considered puzzling in the extreme. It i- quite 
possible that other similar cases — of which many are on record, although 
none so remarkable — may possibly have depended on some similar cause 
personal to the medical attendant. 

The sources of septic poison being thus multifarious, a few words may 
be said as to the mode in which it may be conveyed to the patient. 

Mode in which the Poison may be Conveyed to the Patient. — As en the 
view of puerperal septicaemia which seems most to agree w itli recorded 
facts the poison, from whatever source it may be derived, must come 
into actual contact with lesions of continuity in the generative tract, ii 
is obvious that one method of conveyance may he on the hands of the 
accoucheur. That this is a possibility, and that the disease lias often been 
unhappily conveyed in this way, no one can doubt. Still, it would be 
unfair in the extreme to conclude that this is the only way in which 
infection may arise. In town-practice, especially, there are many other 
ways in which septic matter may reach the patient. The aurse may be 
the means of communication, and, if she have been in contact with sep- 
tic matter, she is even more likely than the medical attendant 1<> convey 
it when washing the genitals during the first lew days after delivery, the 
time that absorption i- most apt to occur. Barnes relate- a whole series 
of cases occurring in a suburb of London in the practice of different 
practitioner-, every one of which was attended by the same imr-c. 

Again, septic matter may be carried in sponges, linen, .-nid other articles. 
What i- more likely, for example, than (hat a careless nurse might lise 
an imperfectly-washed sponge on which discharge ha- been allowed t<> 
remain and decompose? Nor do I see any reason to question the possi- 
bility of infection from septic matter suspended in the atmosphere \ and 
in lying-in hospitals, where many women are congregated together, there 
can be little doubt that this is a common origin of the di-. ■;!-.•. It 
tain, whatever view we may take of the character of the septic material, 

1 This is stated on the authority of an obstetrical contemporary of Dr. Rutter 
Am>er. Journ. of M<<l. Science^ April. 1875, p. 17 1. 

The author quotes from the editor. Dr Rutter had an oaaena which in tin* 

disfigured him from it- «flt-<t upon the cont ■ of his nose. M was unfortunately 

inoculated in his index finger from a patient, and neglected tli«- pustule. He had 95 
cases of puerperal septicaemia in four years and nine months, with 18 <l<;uli>. 
question of Dr. Meigs, who waa a non-contagionisl in regard to puerperal peritonitis, 
was remarkably apposite: "Did he distil a subtle essence which I I with himr 

— Harris's note to third American edition. 



604 THE PUERPERAL STATE. 

that it must be in a state of very minute subdivision, and there is no 
theoretical difficulty in the assumption of its being conveyed by the 
atmosphere. 

Conduct of the Practitioner in Relation to the Disease. — This question 
naturally involves a reference to the duty of those who are unfortunately 
brought into contact with septic matter in any form, either in a patient 
suffering from puerperal septicaemia, zymotic disease, or offensive dis- 
charges. The practitioner cannot always avoid such contact, and it is 
practically impossible to relinquish obstetric work every time that he is 
in attendance on a case from which contagion may be carried. Nor do 
I believe, especially in these days when the use of antiseptics is so well 
understood, that it is essential. It was otherwise when antiseptics were 
not employed, but I can scarcely conceive any case in which the risk of 
infection cannot be prevented by proper care. The danger I believe to 
be chiefly in not recognizing the possible risk and in neglecting the use 
of proper precautions. It it impossible, therefore, to urge too strongly 
the necessity of extreme, and even exaggerated, care in this direction. 
The practitioner should accustom himself, as much as possible, to use 
the left hand only in touching patients suffering from infectious diseases, 
as that which is not used under ordinary circumstances in obstetric man- 
ipulations. He should be most careful in the frequent employment of 
antiseptics in washing his hands, such as Condy's fluid, carbolic acid, or 
the l-in-1000 solution of perchloride of mercury. Clothing should be 
changed on leaving an infectious case. Much more care than is usually 
practised should be taken by nurses, especially in securing perfect clean- 
liness in everything brought into contact with the patient. When, how- 
ever, a practitioner is in actual and constant attendance on a case of 
puerperal septicaemia — when he is visiting his patient many times a day, 
especially if he be himself washing out the uterus with antiseptic lotions 
— it is certain that he cannot deliver other patients with safety ; and he 
should secure the assistance of a brother-practitioner, although there 
seems no reason why he should not visit women already confined in 
whom he has not to make vaginal examinations. 

Projohylaxis of Septicemia. — If the views here inculcated as to the 
nature of, and mode of infection in, puerperal septicaemia be correct, it 
is obvious that much may be done in the way of prophylaxis. A per- 
fectly aseptic management of puerperal women is practically impossible. 
In many lying-in institutions on the Continent, and in some in this 
country, very rigid rules have been laid down to prevent the possibility 
of infective matter being conveyed to the patient either on the hands of 
the attendants or on instruments, napkins, and the like, and, it is said, 
with very satisfactory results. As the risk is much greater when lying- 
in women are collected together, such precautions, which this is not the 
place to discuss, are absolutely indicated. They are not, however, appli- 
cable in ordinary private practice, but there are certain simple precautions, 
which every one might adopt without trouble, which will materially 
lessen the risk of septic poisoning. Amongst these may be indicated 
the use of antiseptic lotions, with which the practitioner and nurse should 
always wash their hands before attending any case or touching the geni- 
tal organs ; the use of carbolized oil, l-in-8, for lubricating the fingers. 



P UERPERA L SEP TIC \ EM I A . 605 

catheter, forceps, etc. ; syringing out the vagina night and morning with 
diluted Condv's fluid; rigid attention to cleanliness in bedding, nap- 
kins, etc. Precautions such as these, although they may appear to some 
frivolous and useless, indicate a recognition of danger and an endeavor 
to remove it, and, if they were generally inculcated on nurses (see note, 
p. 555) and others, might go far to prevent the occurrence of septic 
mischief. 

Nature of the Septic Poison. — As to the precise character of the septic 
poison, although of late much has been said about it, and there is good 
reason to believe that further research may throw light on this obscure sub- 
ject, too little is known to justify any positive statement. With regard to 
the influence of minute micro-organisms and their supposed connection 
with the production of the disease, this is especially the case. The 
recent researches of Heiberg, Von Recklinghausen, Steurer, and others 
have shown that in puerperal septicaemia, as in surgical fever, erysipelas, 
and other infectious diseases, chain-like micrococci in large numbers may 
be traced passing between the muscular and connective-tissue fibres 
through the lymphatics, and thus into the general circulation, and that 
they may be found in various organs and pathological product-. These 
observations are of much importance, as tending to confirm by scientific 
observation the intimate relation between these various forms of disease 
which has long been believed to exist. It may be taken as certain that 
these bodies bear an intimate and important relation to the disease; but 
whether they themselves form the septic matter or carry it, or whether 
they are mere accidental concomitants of the pysemic processes, it is im- 
possible, in the present state of our knowledge, to state, and I therefore 
prefer to dwell on that part of the subject which is of clinical import- 
ance, rather than enter into speculative theories which may to-morrow 
prove to be valueless. 1 

Channels of Diffusion. — Passing on to the channel- of diffusion through 
which the septic matter may act, we have to consider its effects <>n the 
structure- with which it is brought into contact and the mode in which 
it may infect the system at large; and this will include a consideration 
of the pathological phenomena. 

Local changes consequent on the absorption of the poison are pretty 
constant, and of these we may form an intelligible idea by thinking of 
them a- similar in character ami causation to those which we have the 
opportunity of studying when septic matter is applied i«> a wound open 
to observation ; as, for example, in cases of blood-poisoning following a 
dissection wound. Distinct traces of local action are not of invariable 
occurrence, and in some of the worst class of cases, when the amount of 
septic matter is great and it- absorption rapid, death may occur aft 
illness of short duration, but greal intensity, and before appreciable local 
changes, either at the site of absorption or in the system at large, have 
had time to develop themselves. 'I'd'- fact that puerperal fi 
prove fatal without leaving any tangible post-mortem signs has often 
been pointed out, such cases most hSequently occurring during th 

1 For the latent information on this point see "< tar Present Knowledge of the ReU- 
tions between Micro-organisms and Puerperal Fever," bj Carl Lomer, M D., 

Joarn. of Ob-<1<t.. -July. 1884. 



606 THE PUERPERAL STATE. 

demic prevalence of the disease in lying-in hospitals. There can be little 
doubt, however, that in such cases of intense septicaemia marked patho- 
logical changes exist in the form of alterations of the blood and degene- 
rations of tissue, but not of a character which, can be detected by an 
ordinary post-mortem examination. In the great majority of cases indi- 
cations of the disease exist at the site of absorption. These are described 
by pathologists as identical in their character with the inflammatory 
oedema which occurs in connection with phlegmonous erysipelas. If 
lacerations exist in the cervix or vagina, they take on unhealthy action, 
their edges swell, and their surfaces become covered with a yellowish 
coat similar in appearance to diphtheritic membrane. The mucous 
membrane of the uterus is also generally found to be affected, and in 
a degree varying with the intensity of the local septic process. There 
is evidence of severe endometritis, and very frequently the whole lining 
of the uterus is profoundly altered, softened, covered with patches of 
diphtheritic deposit, and, it may be, in a state of general necrosis. In 
the severer cases these changes affect the muscular tissue of the uterus, 
which is found to be swollen, soft, imperfectly contracted, and even 
partially necrosed — a condition which is likened by Heiberg to hospital 
gangrene. The connective tissue surrounding the generative tract is also 
swollen and cedematous, and the inflammation may in this way reach 
the peritoneum, although peritonitis, so often observed in puerperal sep- 
ticaemia, does not necessarily depend on the direct transmission of inflam- 
mation from the pelvic connective tissue, but is more often a secondary 
phenomenon. 

Channels through which Systemic Infection is Produced. — The chan- 
nels through which general systemic infection may supervene are the 
lymphatics and the venous sinuses, the former being by far the most 
important. Recent researches have shown the great number and com- 
plexity of the lymphatics in connection with the pelvic viscera, and 
marked traces of the absorption of septic matter are almost always to be 
found, except in those very intense cases, already alluded to, in which 
no appreciable post-mortem signs are discoverable. The septic matter 
is probably absorbed from the lymph-spaces abounding in the connec- 
tive tissue, and carried along the lymphatic canals to the nearest glands. 
The result is inflammation of their coats and thrombosis of their con- 
tents, which may be seen on section as a creamy, purulent substance. 
The absorption of septic material may, as Virchow has shown, be de- 
layed by the local changes produced in the lymphatics and in the glands 
with which they communicate, which are therefore conservative in their 
action ; and the further progress of the case may in this way be stopped 
and local inflammation alone result, such cases being believed by Hei- 
berg to be examples of abortive pyaemia. On the other hand, the free 
septic material may be too abundant and intense to be so arrested ; it 
may pass on through the lymph-canals and glands until it reaches the 
blood-current through the thoracic duct, and so produces a general 
blood-infection. This mode of absorption of septic matter, and the 
tendency of the glands to arrest its further progress, serve to explain 
the progressive character of many cases in which fresh exacerbations seem 
to occur from time to time, since fresh quantities of poison, generated at 



PUERPERAL SEPTICEMIA. 607 

its source of origin, may be absorbed as the case progresses. The ute- 
rine veins are supposed by D'Espine to be the channel of absorption in 
the intense form of disease which proves fatal very shortly after delivery, 
too soon for the more gradual process of lymphatic absorption to have 
become established. It is evident that the veins are not likely to act in 
this way, since they must, under ordinary circumstances, be completely 
occluded by thrombi, otherwise hemorrhage would occur. If, however, 
uterine contraction be incomplete, the occlusion of the venous sinuses 
may be imperfect, and absorption of septic material through them may 
then take place. Some writers have laid great stress on imperfect ute- 
rine contraction in predisposing to septicaemia, and its influence may thus 
be well explained. The veins may bear an important part in the produc- 
tion of septicaemia independent of the direct absorption of septic matter 
through them by means of the detachment of minute portions of their 
occluding thrombi in the form of emboli. If phlegmonous inflammation 
occur in the immediate vicinity of the veins, the thrombi they contain 
may become infected. When once blood-infection has occurred by any 
of these channels, general septicaemia, the so-called puerperal fever, is 
developed. 

Pathological Phenomena observed after Gerwral Wood-Infection. — 
The variety of pathological phenomena found on post-mortem examina- 
tion has had much to do with the prevalent confusion as to the nature 
of the disease. This has resulted in the description of many distinct 
forms of puerperal fever, the most marked pathological alteration having 
been taken to be the essential element of the disease. As a matter of 
fact, there is no doubt that various types of pathological change arc met 
with. Heiberg describes four chief classes which arc by no means dis- 
tinctly separated from one another, are often found simultaneously in 
the same subject, and are certainly not to be distinguished by the symp- 
toms during life. 

lnhii.se Cases without Marked Post-mortem Signs. — Of these, the lir-t 

is the class of cases in which no appreciable morbid phe nena are 

found after death. This formidable and fatal form of the tli-<M-*- h:i~ 
long been well known, and i- th.it described by some of our authors as 
adynamic or malignant puerperal fever. It i- the variety which was so 
prevalent in our lying-in hospitals, and which Ramsbotham talks of as 
being second only to cholera in the severity and suddenness of it- onset 
and in the rapidity with which it carried oil' it- victims. It is quite 
erroneous to suppose that the existence of pathological changes in this 
form of disease nas never been recognized. Even with the coarse meth- 
od- of examination formerly used, the occurrence of ;i fluid and altered 
state of the blood and ecchymoses in connection with various organs 
especially the lungs, spleen, and kidney — were noticed and special h 
described by Copland in his Dictionary of Medicine, More recently il 
has been clearly proved by the microscope thai there exists, in addition, 
the commencement of inflammation in mosl of the tissues, shown l«\ 
cloudy swellings and granular infiltration and disintegration "f the cell- 
elements; proving thai the blood, heavil) charged with septic matter, 
had set up morbid action wherever it circulated, the patient succumbing 
before this had time to develop. 



608 THE PUERPERAL STATE. 

Cases characterized by Inflammation of the Serous Membranes. — In the 
second type, and that perhaps most commonly met with, the morbid 
changes are more frequently found in the serous membranes, in the pleura, 
in the pericardium, but, above all, in the peritoneum, the alterations in 
which have long attracted notice, and have been taken by many writers 
as proving peritonitis to be the main element of the disease. Evidences of 
more or less peritonitis are very general. In the more severe cases there 
is little or no exudation of plastic lymph, such as is found in peritonitis 
unassociated with septicaemia. There is a greater or less quantity of 
brownish serum only, the coils of intestine, distended with flatus and 
highly congested, being surrounded by it. More often there are patchy 
deposits of fibrinous exudation over many of the viscera, the fundus 
uteri, the under surface of the liver, and the distended intestines. There 
is then also a considerable quantity of sero-purulent fluid in the abdom- 
inal cavity. The pleural cavities may also exhibit similar traces of 
inflammatory action, containing imperfectly-organized lympth and sero- 
purulent fluid. Schroeder states that pleurisy is more often the direct 
result of transmission of inflammation through the substance of the dia- 
phragm or lung than a secondary consequence of the septicaemia. In 
like manner, evidences of pericarditis may exist, the surface of the peri- 
cardium being highly injected and its cavity containing serous fluid. 
Inflammation of the synovial membranes of the larger joints, occasion- 
ally ending in suppuration, is not uncommon, and may probably be best 
included under this class of cases. 

Gases characterized by Changes in the Mucous Membranes. — In the 
third type the mucous membranes appear to bear the brunt of the dis- 
ease. The pathological changes are most marked in the mucous mem- 
brane lining the intestines, which is highly congested, and even ulcerated 
in patches, with numerous small spots of blood extravasated in the sub- 
mucous tissue. Similar small apoplectic effusions have been observed 
in the substance of the kidneys and under the mucous membrane of the 
bladder. Pneumonia is of common occurrence. In most cases it is 
probably secondary to the impaction of minute emboli in the smaller 
branches of the pulmonary artery, but it may doubtless arise from inde- 
pendent inflammation of the lung-tissue, and will then be included in 
the class of cases now under consideration. 

Cases characterized by the Impaction of Infected Emboli and Second- 
ary Inflammation and Abscess. — The fourth class of pathological phe- 
nomena are those which are produced chiefly by the impaction of minute 
infected emboli in small vessels in various parts of the body. These 
are the cases which most closely resemble surgical pyaemia, both in their 
symptoms and post-mortem signs, and which by many writers are 
described under the name of puerperal pyaemia. The dependence of 
puerperal fever on phlebitis of the uterine veins was a favorite theory, 
and in a large proportion of cases the coats of the veins show signs of 
inflammation, their canals being occupied with thrombi in a more or 
less advanced state of disintegration. The mode in which these thrombi 
may become infected has been shown by Babnoif, who has proved that 
leucocytes may penetrate the coats of the vein, and, entering its con- 
tained coagulum, may set up disintegration and suppuration. This 



PUERPERAL SEPTICEMIA. 



609 



observation brings these pyemic forms of disease into close relation with 
septicaemia, such as we have been studying, and justifies the conclusion 
of Verneuil that purulent infection is not a distinct disease, but only a 
termination of septicaemia, with which it ought to be studied. We have, 
moreover, to differentiate these results of embolism from those considered 
in a subsequent chapter, the characteristic of these cases being the infected 
nature of the minute emboli. Localized inflammations and abscesses 
from the impaction of minute capillary emboli are found in many parts 
of the body — most frequently in the lungs, then in the kidneys, spleen, 
and liver, and also in the muscles and connective tissues. Pathologists 
are by no means agreed as to the invariable dependence of these on 
embolism, nor is it possible to prove their origin from this source by 
post-mortem examination. Some attribute all such cases to embolism ; 
others think that they may be the results of primary septicemic inflam- 
mation. It has been proved by Weber that minute infected emboli may 
pass through the lung capillaries ; and this disposes of one argument 
against the embolic theory based on the supposed impossibility of their 
passage. It is probable that both causes may operate, and that localized 
inflammations occurring a short time after delivery are directly produced 



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bv tin? infected blood, while those occurring after the lapse of some time, 
as in the second or third week, depend upon embolism, 

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logical changes which accompany it, it will not be a matter of surprise 



39 



610 



THE PUERPERAL STATE. 



to find that the symptoms are also very various in different cases. This 
can readily be explained by the amount and virulence of the poison 
absorbed, the channels of infection, and the organs which are chiefly 
implicated ; but it renders it very difficult to describe the disease satis- 
factorily. 

The symptoms generally show themselves within two or three days 
after delivery. As infection most often occurs during labor, or, in cases 
which are autogenetic, within a short time afterward, and before the 
lesions of continuity in the generative tract have commenced to cicatrize, 

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DAY OF 

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it can be understood why septicaemia rarely commences later than the 
fourth or fifth day. 

The Early Symptoms are not Well Marled. — In the great majority of 
cases the disease begins insidiously. There are, generally, some chilli- 
ness and rigor, but by no means always, and even when present they 
frequently escape observation or are referred to some transient cause. 
The first symptom which excites attention is a rise in the pulse, which 
may vary from 100 to 140 or more, according to the severity of the 
attack ; and the thermometer will also show that the temperature is raised 
to 102°, or in bad cases even to 104° or 106°. Still, it must be borne 
in mind that both the pulse and temperature may be increased in the 
puerperal state from transient causes, and do not, of themselves, justify 
the diagnosis of septicaemia. 



PUERPERAL SEPTICEMIA. 



611 



Symptoms of Intense Septiccemia. — In the more intense class of cases, 
in which the whole system seems overwhelmed with the severity of the 
attack, the disease progresses with great rapidity and often without any 
appreciable indication of local complication. The pulse is very rapid, 
small, and feeble, varying from 120 to 140, and there is generally a 
temperature of 103° or 104°. In the worst form of cases the tempera- 
ture is steadily high, without marked remissions. (See Figs. 193, 194, 
and 195.) There may be little or no pain, or there may be slight ten- 
derness on pressure over the abdomen or uterus, and as the disease pro- 
gresses the intestines get largely distended with flatus, so that intense 
tympanites often form a most distressing symptom. The countenance is 
sallow, sunken, and has a very anxious expression. As a rule, intelli- 
gence is unimpaired, and this may be the case even in the worst forms 
of the disease and up to the period of death. At other times there is 
a good deal of low muttering delirium, which often occurs at night 
alone, and alternates with intervals of complete consciousness, but is 
occasionally intensified for a short time into a more acute form. Diar- 
rhoea and vomiting are of very frequent occurrence; by the latter dark, 
grumous, coffee-ground substances are ejected. The diarrhoea is occa- 

Fig. 195. 



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sionallv verv profuse and uncontrollable ; in mild cases ii seems • " relieve 
the severity of the symptoms. The tongue is moist and loaded with 
sordes, but sometimes it gets dark and dry, especially toward the termi- 
nation of the disease. The lochia are generally suppressed or altered in 
character, and sometimes they have ;i highly offensive odor, especially 



612 



THE PUERPERAL STATE. 



when the disease is autogenetic. The breathing is hurried and panting, 
and the breath itself has a very characteristic, heavy, sweetish odor. 
The secretion of milk is often, but not always, arrested. 

Duration of the Disease. — With more or less of these symptoms the 
case goes on, and when it ends fatally it generally does so within a week, 
the fatal termination being indicated by more weakness, rapid, thread- 
like, or intermittent pulse, marked delirium, great tympanites, and some- 
times a sudden fall of temperature, until at last the patient sinks with 
all the symptoms of profound exhaustion. 

Variety of Symptoms in Different Cases. — In milder cases similar 
symptoms, variously modified and combined, are present. It is seldom 

Fig. 196. 



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that two precisely similar cases are met with ; in some the rapid weak 
pulse is most marked ; in others, abdominal distension, vomiting, diar- 
rhoea, or delirium. 

Symptoms of Peritonitis. — Local complications variously modify 'he 
symptoms and course of the disease. The most common is peritonitis, 
so much so that with some authors puerperal fever and puerperal peri- 
tonitis are synonymous terms. Here the first symptom is severe abdomi- 
nal pain, commencing at the lower part of the abdomen, where the 
uterus is felt enlarged and tender. As the abdominal pain and tender- 
ness spread, the sufferings of the patient greatly increase, the ^ intestines 
become enormously distended with flatus, and the breathing is entirely 



PUERPERAL SEPTICEMIA. 



613 



thoracic in consequence of the upward displacement of the diaphragm 
and the fact that the abdominal muscles are instinctively kept as much 
in repose as possible. The patient lies on her back with her knees drawn 
up, and sometimes cannot bear the slightest pressure of the bed-clothes. 
There is generally much vomiting, and often severe diarrhoea. The 
temperature generally ranges from 102° to 104°, or even 106°, and is 
subject to occasional exacerbations and remissions, possibly depending 
on fresh absorption of septic matter. (See Temperature charts. Figs, 
196, 197, and 198.) The case generally lasts for a week or more, the 

Fig. 197. 



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symptoms going on from bad to worse and the patient dying exhaust- 
ed. D'Espine points out thai rigors, with exacerbations of the general 
symptoms, not (infrequently occur about the sixth orseventh day, which 
he attributes to fresh systemic infection from fetid pus in the peritonea] 
cavity. It musl noi be supposed that all these symptoms are necessarily 
present when the peritonitic complication exists. Pain especially is often 
entirely absent, and I have seen cases in which post-mortem examina- 
tion proved the existence of peritonitis in a very marl 
which pain was entirely absent. Sometimes the pain is only Blight, and 
amounts to little more than tenderness over the aterus. 

Symptoms of other Local Complications. — Symptoms of other local 
complications are characterized by their own special symptoms; thus, 
pneumonia by dyspnoea, cough, dulness, etc.; pericarditis by the cha- 



614 



THE PUERPERAL STATE. 



ractefistic rub ; pleurisy by dulness on percussion ; kidney affection by 
albuminuria and the presence of casts ; liver complication by jaundice ; 
and so on. 

Pycemic Forms of the Disease. — The course of the disease is not 
always so intense and rapid, being in some cases of a more chronic cha- 



Fig. 198. 



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meter and lasting many weeks. The symptoms in the early stage are 
often indistinguishable from those already described, and it is generally 
only after the second week that indications of purulent infection develop 
themselves. Then we often have recurrent and very severe rigors, with 
marked elevations and remissions of temperature. At the same time 
there is generally an exacerbation of the general symptoms, a peculiar 
yellowish discoloration of the skin, and occasionally well-developed 
jaundice. Transient patches of erythema are not uncommonly observed 
on various parts of the skin, and such eruptions have often been mis- 
taken for those of scarlet fever or other zymotic disease. Localized 
inflammations and suppuration may rapidly follow. Amongst the 
most common is inflammation or even suppuration of the joints — the 
knees, shoulders, or hips — which is preceded by difficulty of movement, 
swelling, and very acute pain. Large collections of pus in various parts 
of the muscles and conective tissues are not rare. Suppurative inflam- 
mation may also be found in connection with many organs, as in the 
eye, in the pleura, pericardium, or lungs ; each of which will, of course, 



PUERPERAL SEPTICEMIA. 615 

give rise to characteristic symptoms, more or less modified by the type 
of the disease and the intensity of the inflammation. 

Puerperal Malarial Fever. — There is a peculiar form of febrile dis- 
turbance which sometimes occurs in the puerperal state, and which is 
apt to be confounded with septicaemia, to which attention has been speci- 
ally directed by Fordyce Barker 1 under the name of " puerperal mala- 
rial fever." It is specially apt to be met with in women who have been 
exposed to malarial poison during their former lives, the recurrence of 
the fever being probably determined by the puerperal state. Of tin- I 
have seen several very well-marked examples in ladies who have for- 
merly contracted fever or ague in India. One of my patients, who has 
long been in India and suffered from intermittent fever for year-, i- 
invariably attacked with it after delivery, and herself warned me of the 
fact the first time I attended her. The diagnosis is not always easy. 
Barker insists on the fact that puerperal malarial fever generally com- 
mences after the fifth day from delivery, while septicaemia almost always 
does so before that time. In the malarial fever, moreover, the intermis- 
sions are much more marked, while there are frequently-recurring chills 
or rigors, which is not the case in septicaemia. 

Treatment. — In considering the all-important subject of treatment the 
views of the practitioner are naturally biassed by the theory he has 
adopted of the nature of the disease. If that here inculcated be correct, 
the indications we have to bear in mind are — 1st, to discover, if possible, 
the source of the poison, in the hope of arresting further septic absorp- 
tion; 2d, to keep the patient alive until the effects of the poison are 
worn off; and, 3d, to treat any local complications that may arise. 

The Use of Antiseptic Injections. — The first Is likely to be of great 
importance in cases of self-infection, as fresh quantities of septic matter 
may be from time to time absorbed. We, fortunately, are in possession 
of a powerful means of preventing further absorption by the applica- 
tion of antiseptics to the interior of the uterus and to the canal of the 
vagina. 2 This is especially valuable when the existence of decomposing 
coagula or other sources of septic matter is suspected in the uterine 
cavity, or when offensive discharges are present Disinfection is readily 

1 "Puerpera1 Malarial Fever," Amer. Journ. of Ofafet., April. 1880 
2 My colleague, Dr. 1 laves, has invented :i silver tube for the purpose of administering 
such uitra-uterine injections' (Fig. L99), which answers its purpose admirably. The 

. 199. 




Hayes's Tube for Intra uterine Injections. 



numerous apertures nt its extremity allow <>f a number "i" minufc of fluid 

being thrown oui in theform of a Bpray over the interior "t' the litems, the complete 
bathing of its surface and washing oui of ii> cavity being thus ensured. It is, more- 
over, introduced more easily than the ordinary vaginal pipe, and can be attached u> a 

Higginson syringe. 



616 



THE PUERPERAL STATE. 



Fig. 200 . 



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7" 


8* 


9* 


IO& | 1 1»> 



Fig. 201. 



accomplished by washing out the uterine cavity at least twice daily by 
means of a Higginson's syringe with a long vaginal pipe attached. The 

results are sometimes very remarkable, 
the threatening symptoms rapidly disap- 
pearing, and the temperature and pulse 
tailing so soon after the use of the anti- 
septic injections as to leave no doubt of 
the beneficial effects of the treatment. 
I cannot better illustrate the advantages 
of this treatment than by this tempera- 
ture chart (Fig. 200), which is from a case 
which came under my observation in 
the out-door practice of King's College 
Hospital. It was that of a healthy 
woman, thirty-six years of age, who 
had an easy and natural labor. Noth- 
ing remarkable was observed until the 
third day after delivery, when the temperature was found to be slightly 
increased. On the morning of the eighth day the temperature had risen 
to 105.8°. She was delirious, with a rapid, thready pulse, clammy per- 
spiration, tympanitic abdomen, and her 
general condition indicated the most ur- 
gent danger. On vaginal examination 
a piece of compressed and putrid pla- 
centa was found in the os. This w T as 
removed by my colleague, Dr. Hayes, 
and the uterus thoroughly washed out 
with Condy's fluid and water. The 
same evening the temperature had sunk 
to 99°, and the general symptoms were 
much improved. The next day there was 
a slight return of offensive discharge 
and an aggravation of the symptoms. 
After again washing out the uterus the 
temperature fell, and from that date 
the patient convalesced without a single 
bad symptom (Fig. 201). 

This is a very well-marked example 
of the value of local antiseptic treat- 
ment, and I have seen many cases of 
the same kind. It should therefore 
never be omitted in all cases in which 
self-infection is possible ; and, indeed, 
even when there is no reason to suspect 
the presence of a local focus of infec- 
tion the use of antiseptic lotions is ad- 
visable as a matter of precaution, since 
it can do no harm and is generally com- 
forting to the patient. Any antiseptic may be used, such as a weak solu- 
tion of carbolic acid, 1 in 50, or of tincture of iodine, or Condy's fluid 



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PUERPERAL SEPTICuEMTA. 617 

largely diluted. I generally use the two latter alternately, the one in 
the morning, the other in the evening. Occasionally I have employed a 
l-in-50 solution of carbolic acid, with about 5 grain- to the mm 
iodoform suspended in it. This has the advantage of not only being a 
very powerful antiseptic, but of acting more continuously in consequence 
of the powdered iodoform remaining partially attached to the uterine 
w T alls; or, as some have advised, an iodoform pessary may he placed 
in the uterine cavity. The nozzle of the syringe should Ik- guided well 
through the cervix, and the cavity of the uterus thoroughly washed 
out until the fluid that issues from the vagina i- no longer discolored. 
As the os is always patulous, there is no risk of producing the tr<>nl>le- 
some symptoms of uterine colic which occasionally follow the use of 
intra-uterine injections in the unimpregnated state. It is quite useless 
to entrust the injection to the nurse, and it should be performed ai least 
twice daily by the practitioner himself in all cases in which the dis- 
charges are offensive. It is not advisable, however, that such injections 
should be used indiscriminately, since they are not entirely free from 
risk, nor should they be continued for more than a few day-. The vulva 
should in all cases be carefully inspected, with the view of ascertaining 
if the source of infection be not some local slough or necrotic ulcer about 
the perineum or orifice of the vagina, in which case it- surface Bhould be 
freely covered with iodoform. I have seen more than one instance in 
which this simple procedure has sufficed to cut short symptoms of a very 
threatening character. 

Administration of Food and Stimulants. — In a disease charact 
by so marked a tendency to prostration the importance of sustaining 
the vital powers by an abundance of easily-assimilated nourishment 
cannot be overrated. Strong beef-tea or other forms of animal soup, 
milk, alone or mixed either with lime- or so'da-water, and the yelk of 
eggs beat up with milk and brandy, should be given at short intervals, 
and in as large quantities as the patient can be induced to take; and the 
value of thoroughly efficient nursing will be especially apparent in the 
management of tin- important part of the treatment A- there is fre- 
quently a tendency to nausea, the patient may resist the administration 
of food, and the resources of th«- practitioner will he taxed in adminis- 
tering it in such form and variety a- will prove least distasteful I 
erally speaking, not more than one or two hours Bhould 1"' allowed to 

elapse without SO/ne nutriment being given. 'I'll.- am. .inn of -timnlant 

required will vary with the intensity of the jymptoma and the indica- 
tions <»f debility. Generally, stimulants are well borne, prove decidedly 
beneficial, and require to be given pretty freely. I" lerate 

severity a tablespoonftd of good old brandy or whiski four \\<>\w- 

may suffice; but when the pulse is very rapid and threadjr, when there 
is much low delirium, tympanites, or sweating (indicat found 

exhaustion), it may be advisable to give them in much larger quantities 
and at shorter intervals. The careful practitioner will closely watch the 
effects produced, and regulate the amount by tl 
rather than by any fixed rule; but in - d.t or I 

ounces of brandy, or even more, in the tw< nty-four boon ma; 
with decided benefit. 



618 THE PUERPERAL STATE. 

Venesection not Admissable. — Venesection, both general and local, was 
long considered a sheet-anchor dn this disease. Modern views are, how- 
ever, entirely opposed to its use ; and in a disease characterized by so 
profound an alteration of the blood and so much prostration it is too 
dangerous a remedy to employ, although it is possible that it might alle- 
viate temporarily the severity of some of the symptoms, especially in 
cases in which peritonitis is well marked and much local pain and ten- 
derness are present. [*] 

Medicinal Treatment — The rational indications in medicinal treatment 
are to lessen the force of the circulation as much as is possible without 
favoring exhaustion, and to diminish the temperature. 

Use of Arterial Sedatives. — For the former purpose Barker strongly 
advocates the use of veratrum viride, in doses of five drops of the tinc- 
ture every hour, until the pulse falls to below 100, when its effects are 
subsequently kept up by two or three drops every second hour. Of this 
drug I have no personal experience, but I have extensively used minute 
doses of tincture of aconite for the same purpose, and when carefully 
given I believe it to be a most valuable remedy. The way I have 
administered it is to give a single drop of the tincture, at first every 
half hour, increasing the interval of administration according to the 
effect produced. Generally, after giving four or five doses at intervals 
of half an hour, the pulse begins to fall, and afterward a few doses, at 
intervals of one or two hours, will suffice to prevent the heart's action 
rising to its former rapidity. The advantage of thus modifying cardiac 
action with the view of preventing excessive waste of tissue cannot be 
questioned. It is evident that so powerful a remedy must not be used 
without the most careful supervision, for, if continued too long or given 
at too frequent intervals, it may unduly depress the circulation, and do 
more harm than good. It is necessary, therefore, that the practitioner 
should constantly watch the effect of the drug, and stop it if the pulse 
become very weak or if it intermit. It is most likely to be useful at an 
early stage of the disease before much exhaustion is present, and then 
only when the pulse is of a certain force and volume. Barker says of 
the veratrum viride, what is also true of aconite, that " it should not be 
given in those cases in which rapid prostration is manifested by a feeble, 
thread-like, irregular pulse, profuse sweats, and cold extremities." 

Reduction of Temperature. — The reduction of temperature must form 
an important part of our treatment, and for this purpose many agents 
are at our disposal. 

Quinine. — Quinine in large doses, of from 10 to 30 grains, has been 
much used for this purpose, especially in Germany. After its exhibition 

[* I believe that the entire abandonment of venesection has been a grave error, and 
that where there is early in the attack a high pulse, with great abdominal distension 
and tenderness and a decided elevation of temperature, we ought to bleed the patient, 
sitting, at once, and to such a degree as to produce a decided impression. One of the 
worst cases I ever saw was cured in this way. The woman was delivered at 8£ p. M. 
of one day, and the disease manifested itself in twenty hours. At 9 the next morning 
she was apparently doing well ; at 1 she was in great suffering, and could not bear her 
abdomen to be touched ; vs. f ^xvj : at 9 p. m., symptoms more grave; vs. fjxl in a sit- 
ting posture until she felt sick. At 10 P. M. pulse 150: in twenty-four hours from this 
no fever and very little pain: in three days regarded as out of danger. Saw her in 
robust health, with her child living, a year later. — Ed.] 



PUERPERAL SEPTICEMIA. 619 

the temperature frequently falls one or two degrees. It may be given 
morning and evening. Unpleasant head-symptoms, deafness, and ring- 
ing in the ears often render its continuance for a length of time impossi- 
ble. These may, however, be much lessened by the addition of 10 to 15 
minims of hydrobromic acid to each dose. 

Salicylic Acid. — Salicylic acid, in doses of from 10 to 20 grain-, or 
the salicylate of soda in the same doses, is a valuable antipyretic which 
I have found on the whole more manageable than quinine. Under its 
use the temperature often falls considerably in a short space of time. It 
is, however, apt to depress the circulation, and thus requires to be care- 
folly watched while it is being administered ; and should the pulse 
become very small and feeble it should be discontinued. 

Warburg's Tincture. — In some cases, especially when the fever has 
assumed a remittent type, I have administered with marked benefit a 
drug which is of high repute in India in the worst class of malarious 
remittent fevers, and the almost marvellous effects of which in such 
cases I had myself witnessed in India many years ago. This is the 
so-called "Warburg's tincture," the value of which has been testified 
to by many high authorities, among whom I may mention Dr. Maclean 
of Xetley, Dr. Broadbent, and Sir Alexander Armstrong, the Director- 
General of the Medical Department of the Navy, who informs me that it 
is now supplied to all Her Majesty's ships in the tropics, because it is f< >und 
to be of the utmost value in cases in which quinine has little or no effect. 

Recently its composition has been made public by Dr. Maclean* The 
basis is quinine, in combination with various aromatics and bitter-, some 
of which probably intensify its action. Be this as it may, the testimony 
in favor of the antipyretic action of the remedy is very strong. I have 
found its exhibition followed by a profuse diaphoresis (this being its 
almost invariable effect), and sometimes a rapid amelioration of the 
symptoms. In other cases in which I have tried it, like everything else, 
it has proved of no avail. Of its use in ten malarial cases above alluded 
to Dr. Fordyce Barker says : " For nearly two years past, in those cases 
where the stomach will tolerate it, I have found Warburg's tincture 
much more effective and speedy in producing the results desired than 
the largest doses of quinine." 1 

Application of Cold. — Cold may be advantageously tried in suitable 
cases. The simplest mode of using it is by Thornton'- Ice-cap, by which 
a current of cold water is kept continuously running round the bead. 
This has been found of great value in pyrexia after ovariotomy, and I 
have also found it useful a- a means of reducing temperature in puer- 
peral eases. It is a comforting application, and gives great relief to the 
throbbing headache, which often causes much suffering. Under its use 
the tem perature often falls two or more d ad it ifl easily continued 

day and night. 

In very seriou- ease-, when the temperature ivach<- I ' ,: » and upward, 
the externa] application of cold to the rest of the body may • >'• tried. I 
have elsewhere related 9 a case of puerperal septicemia with byper- 

1 Op. cit., p. 278. 

2 "A Lecture on a Case of Puerperal Septicemia, with Hyperpyrexia, treated by the 

Continuous Application of Cold," Brii, Med, Journ., Nov. 17. I ■ 



620 THE PUERPERAL STATE. 

pyrexia, the temperature continuously ranging over 105°, in which I 
kept the patient for eleven days nearly continuously covered with cloths 
soaked in iced water, by which means only was the temperature kept 
within moderate bounds and life preserved. But this method of treat- 
ment is excessively troublesome and is in no way curative. It is only 
of use in moderating the temperature when it has reached a point at 
which it could not continue long without destroying the patient. I 
should therefore never think of employing it unless the temperature was 
over 105°, and then only as a temporary expedient, requiring incessant 
watching, to be desisted from as soon as the temperature had reached a 
more moderate height. It is clearly impossible to place a puerperal 
patient in a bath, as is practised in hyperpyrexia associated with acute 
rheumatism or typhoid fever. The same effect may, however, be obtained 
by placing her on macintosh sheeting, or, still better, on a water-bed, 
into which cold water is run from time to time, and covering the body 
with towels soaked in iced water, which are frequently renewed by the 
attendant nurses. During the application the temperature should be 
constantly taken, and as soon as it has fallen to 101° the cold applica- 
tions should be discontinued. 

Administration of Turpentine. — Amongst other remedies which have 
been used is turpentine, which was highly thought of by the Dublin 
school. In cases with much tympanitic distension and a small weak 
pulse it is sometimes of unquestionable value, and it probably acts as a 
strong nervine stimulant. Given in doses of 15 to 20 minims, rubbed 
up with mucilage, it can generally be taken in spite of its nauseous 
taste. 

Evacuant Remedies. — Purgatives, diaphoretics, or even emetics, have 
often been employed as eliminants of the poison. The former are 
strongly recommended by Schroecler and other Gernian authorities, and 
in this country they were formerly amongst the most favorite remedies, 
and there is a general concurrence of opinion amongst our older writers 
as to their value, In the first volume of the Obstetrical Journal there 
is a paper by Mr. Morton in which this practice is strongly advocated, 
and some interesting cases are recorded in which it apparently acted 
well. He administers calomel in doses of 3 or 4 grains with compound 
extract of colocynth, so as to keep up a free action of the bowels. It 
seems quite reasonable, when there is constipation, to promote a gentle 
action of the bowels by some mild aperient ; but, bearing in mind that 
severe and exhausting diarrhoea is a common accompaniment of the dis- 
ease, I should myself hesitate to run the risk of inducing it artificially, 
especially as there is no proof whatever that septic matter can really be 
eliminated in this way. At the commencement of the disease, however, 
I have often given one or two aperient doses of calomel with decided 
benefit. 

Internal Antiseptic Remedies. — It is possible that further research will 
give us some means of counteracting the septic state of the blood ; and 
the sulphites and carbolates have been given for this purpose, but as yet 
with no reliable results. 

Tincture of Per chloride of Iron. — The tincture of the perchloride of 
iron naturally suggests itself from its well-known effects in surgical 



PUERPERAL VESOUS THROMBOSIS AND EMBOLISM. 621 

pyaemia. In the less intense forms of the disease, especially when local 
suppurations exist, it is certainly useful, and may be given in doses of 
10 to 20 minims every three or four hours. In very acute cases other 
remedies are more reliable, and the iron has the disadvantage of not 
un frequently causing nausea or vomiting. 

Opiates. — AVhen restlessness, irritation, and want of sleep are promi- 
nent symptoms, sedatives may be required. Under such circumstances 
opiates may be given at night, and Battley's solution, nepenthe, or the 
hypodermic injection of morphia are the forms which answer best. 

Treatment of Local Complications. — Pain and tenderness and local 
complications must be treated on general principles. The distress from 
them is most experienced when peritonitis is well marked. Then warm 
and moist applications, in the form of poultices or fomentations, are very 
useful. Relief is also sometimes obtained from turpentine stupes, and 
when the tympanites is distressing turpentine enemata are very service- 
able. I have found the free application over the abdomen of the flexi- 
ble collodium of the Pharmacopoeia decidedly useful in alleviating the 
suffering from peritonitis. 

Such are the remedies most used in this disease. It is needless to say 
that it is quite impossible to lay down fixed rules for the management 
of any individual case; and it is obvious that if puerperal septicaemia be 
not a special and distinct disease, its judicious treatment must depend on 
the general knowledge of the attendant and on a careful study of the 
symptoms each separate case presents. 



CHAPTER VI. 

PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 

Puerperal Thrombosis, and its Results. — Under the bead of thrombosis 
we may class several important diseases connected with the puerperal 
State which have received far less attention than they deserve. It is 
only of late years that souk — we may probably safely say the majority 
— of those terribly Budden deaths which from time to time occur alter 
delivery have been traced to their true canx — viz. obstruction of the 
right side of the heart and pulmonary arteries from a blood-clot, either 
carried from a distance or, as I shall hope to show, formed in situ. 
Although the result, and, to a great extent, the symptoms, are identical 
in both, still a careful consideration of the history of these two classes 
of cases tends to show that in their causation they are distind and that 
they ought not to he confounded. In the former we have primarily a 
clotting of blood in some pari of the peripheral venous system, and the 
separation of a portion of such a thrombus due to changes undergone 
during retrograde metamorphosis tending to its eventual absorption. In 
the latter we have a local deposition of fibrin, the result of blood-changee 



622 THE PUERPERAL STATE. 

consequent on pregnancy and the puerperal state. The formation of 
such a coagulum in vessels the complete obstruction of which is incom- 
patible with life explains the fatal results. When, however, a coagulum 
chances to be formed in more distant parts of the circulation, the vital 
functions are not immediately interfered with, and we have other phe- 
nomena occurring due to the obstruction. The disease known as phleg- 
masia dolens, I shall presently attempt to show, is one result of blood- 
clot forming in peripheral vessels. But from the evident and tangible 
symptoms it produces it has long been considered an essential and spe- 
cial disease, and the general blood-dyscrasia which produces it, as well 
as other allied states, has not been studied separately. I shall hope to 
show that all these various conditions, dissimilar as they at first sight 
appear, are very closely connected, and that they are in fact due to a 
common cause ; and thus, I think, we shall arrive at a clearer and more 
correct idea of their true nature than if we looked upon them as distinct 
and separate affections, as has been commonly clone. I am aware that 
in phlegmasia dolens, the pathology of which has received perhaps more 
study than that of almost any other puerperal affection, something 
beyond simple obstruction of the venous system of the affected limb is 
probably required to account for the peculiar tense and shining swelling 
which is so characteristic. Whether this be an obstruction of the 
lymphatics, as Dr. Tilbury Fox and others have maintained with much 
show of reason, or whether it is some as yet undiscovered state, further 
investigation is required to show. But it is beyond any doubt that the 
important and essential part of the disease is the presence of a thrombus 
in the vessels ; and I think it will not be difficult to prove that in its 
causation and history it is precisely similar to the more serious cases in 
which the pulmonary arteries are involved. 

It will be well to commence the study of the subject by a considera- 
tion of the conditions which in the puerperal state render the blood so 
peculiarly liable to coagulation, and Ave may then proceed to discuss the 
symptoms and results of the formation of coagula in various parts of 
the circulatory system. 

Conditions which Favor Thrombosis. — The researches of Virchow, 
Benjamin Ball, Humphrey, Richardson, and others have rendered us 
tolerably familiar with the conditions which favor the coagulation of the 
blood in the vessels. These are, chiefly — 1. A stagnant or arrested cir- 
culation ; as, for example, when the blood coagulates in the veins which 
draw blood from the gluteal region in old and bedridden people, or as 
in some forms of pulmonary thrombosis, in which the clots in the 
arteries are probably the result of obstruction in the circulation through 
the lung-capillaries, as in certain cases of emphysema, pneumonia, or 
pulmonary apoplexy. 2. A mechanical obstruction around which 
coagula form, as in certain morbid states of the vessels, or, a better 
example still, secondary coagula which form around a travelled embolus 
impacted in the pulmonary arteries. 3. And, most important of all, in 
which the coagulation is the result of some morbid state of the blood 
itself. Examples of this last condition are frequently met with in the 
course of various diseases, such as rheumatism or fever, in which the 
quantity of fibrin is increased and the blood itself is loaded with morbid 



PUERPERAL VENOUS THROMBOSIS AXD EMBOLISM. 623 

material. Thrombosis from this cause is of by no means infrequent 
occurrence after severe surgical operations, especially such as have 
been attended with much hemorrhage, or when the patient is in a 
weak and anaemic condition. This has been specially dwelt upon as 
a not infrequent source of death after operation by Fayrer and other 
surgeons. 1 

Conditions ivhich Favor Coagulation in the Puerperal State. — But little 
consideration is required to show why thrombosis plays so important a 
part in the puerperal state, for there most of the causes favoring its 
occurrence are present. Probably there is no other condition in which 
they exist in so marked a degree or are so frequently combined. The 
blood contains an excess of fibrin, which largely increases in the latter 
months of utero-gestation, until, as has been pointed out by Andral and 
Gavarret, it not unfrequently contains a third more than the average 
amount present in the non-pregnant state. As soon as delivery is com- 
pleted other causes of blood-dyscrasia come into operation. Involution 
of the largely hypertrophied uterus commences, and the blood is charged 
with a quantity of effete material, which must be present, in greater or 
less amount, until that process is completed. It is an old observation 
that phlegmasia dolens is of very common occurrence in patients who 
have lost much blood during labor. Thus, Dr. Leishman says: " In 
no class of cases has it been so frequently observed as in women whose 
strength lias been reduced to a low ebb by hemorrhage either during or 
after labor ; and this, no doubt, accounts for the observation made by 
Merriman, that it is relatively a common occurrence alter placenta pne- 
via." 2 An examination of the cases in which death results from pul- 
monary thrombosis shows the same facts, as in a large proportion of 
them severe post-partum hemorrhage has occurred. The exhaustion 
following the excessive losses so common alter labor must of itself 
strongly predispose to thrombosis, and, indeed, ]<»-- of blood has been 
distinctly pointed out by Richardson to be one of its mosl common antece- 
dents. "There is," he observes, "a condition which has been long known 
to favor coagulation and fibrinous deposition. I mean loss of blood and 
syncope or exhaustion during impoverished state- of the body." 

Since, then, so many of the predisposing causes of thrombosis are 
present in the puerperal state, it is hardly a matter of astonishment that 
it should be oi frequent occurrence or thai it should lead to conditions 
of serious gravity. And yet the attention of the profession has been for 
the most part limited to a study of one only of the results of tin- tend- 
ency to blood-clotting after delivery, no doubt because of ii- comparative 
frequency and evident symptoms. True, the balance of professional 
opinion has lately held that phlegmasia dolens is chiefly the resulj of 
some morbid condition of the blood, producing plugging of the veins ; 
but the wider view which I am attempting t<» maintain, which would 
bring this disease into close relation with the more rarely observed but 
infinitely important obstructions of the pulmonary arteries, has scarcely, 
if at all, been insisted on. Doubtless, further investigation will ?ho* 
that it is not in these parts of the venous system alone that puerperal 

1 Edin. Med. Journ., March, 1861 : Indian AnnaU of .1/-/., July, 1867. 

2 Leishman, System of ()/>.<htnr.<, p, 710. 



624 THE PUERPERAL STATE. 

thrombosis occurs, but the symptoms and effects of venous obstruction 
elsewhere, important though they may be, are unknown. 

Distinction between Thrombosis and Embolism. — I propose, then, to 
describe the symptoms and pathology of blood-clot in the right side of 
the heart and pulmonary artery. It may be useful here to repeat that 
this is essentially distinct from embolism of the same parts. The latter 
is obstruction due to the impaction of a separated portion of a thrombus 
formed elsewhere, and for its production it is essential that thrombosis 
should have preceded it. Embolism is, in fact, an accident of thrombo- 
sis, not a primary affection. The condition we are now discussing I hold 
to be primary, precisely similar in its causation to the venous obstruction 
which in other situations gives rise to phlegmasia dolens. 

Is Primary Thrombosis in the Pulmonary Arteries Possible f — At the 
threshold of this inquiry we have to meet the objection, started by 
several who have written on this subject, 1 that spontaneous coagulation 
of the blood in the right side of the heart and pulmonary arteries is 
a mechanical and physiological impossibility. This was the view of 
Virchow, who, with his followers, maintained that whenever death from 
pulmonary obstruction occurred an embolus was of necessity the start- 
ing-point of the malady and the nucleus round which secondary deposi- 
tion of fibrin took place. Virchow holds that the primary factor in 
thrombosis is a stagnant state of the blood, and that the impulse im- 
parted to the blood by the right ventricle is of itself sufficient to prevent 
coagulation. It is to be observed that these objections are purely theo- 
retical. Without denying that there is considerable force in the argu- 
ments adduced, I think that the clinical history of these cases strongly 
favors the view of spontaneous coagulation ; and I would apply to the 
theoretical objections advanced the argument used by one of their 
strongest upholders with regard to another disputed point : " Je pre- 
fere laisser la parole aux faits, car devant eux la theorie s'incline." 2 

The anatomical arrangement of the pulmonary arteries shows how 
spontaneous coagulation may be favored in them ; for, as Dr. Humphry 
has pointed out, 3 " the artery breaks up at once into a number of 
branches, which radiate from it, at different angles, to the several parts 
of the lungs. Consequently, a large extent of surface is presented to the 
blood, and there are numerous angular projections into the currents ; 
both which conditions are calculated to induce the spontaneous coagula- 
tion of the fibrin." We know also that thrombosis generally occurs in 
patients of feeble constitution often debilitated by hemorrhage, in whom 
the action of the heart is much weakened. These facts of themselves 
go far to meet the objections of those who deny the possibility of spon- 
taneous coagulation at the roots of the pulmonary arteries. 

Results of Post-mortem Examinations. — The records of post-mortem 
examinations show also that in many of the cases the right side of the 
heart, as well as the larger branches of the pulmonary arteries, contained 
firm, leathery, decolorized, and laminated coagula, which could not have 
been recently formed. The advocates of the purely embolic theory 
maintain that these are secondary coagula formed round an embolus. 

1 See especially Bertin, Des Embolies, p. 46 et seq. 2 Ibid., p. 149. 

3 Humphry, On the Coagulation of the Blood in the Venous System during Life. 



PUERPERAL VEXOUS THROMBOSIS AXD EMBOLISM. 625 

But surely the mechanical causes which are sufficient to prevent sponta- 
neous deposition of fibrin would also suffice to prevent its gathering 
round an embolus — unless, indeed, the obstruction was sufficient to 
arrest the circulation altogether, when death would occur before there 
was any time for a secondary deposit. Before we can admit the possi- 
bility of embolism we must have at least one factor — that is, thrombosis 
in a peripheral vessel — from which an embolus can come. In many of 
the recorded cases nothing of the kind was found, and although, as is 
argued, this may have been overlooked, yet such an oversight can hardly 
always have been made. 

Clinical Facts Support this View. — The strongest argument, however, 
in favor of the spontaneous origin of pulmonary thrombosis is one which 
I originally pointed out in a series of papers "On Thrombosis and Em- 
bolism of the Pulmonary Artery as a Cause of Death in the Puerperal 
State." x I there showed, from a careful analysis of 25 cases of sudden 
death after delivery in which accurate post-mortem examinations had 
been made, that cases of spontaneous thrombosis and embolism may be 
divided from each other by a clear line of demarcation, depending on 
the period after delivery at which the fatal result occurs. In 7 out of 
these cases there was distinct evidence of embolism, and in them death 
occurred at a remote period after delivery; in none before the nineteenth 
day. This contrasts remarkably with the cases in which the post-mortem 
examination afforded no evidence of embolism. These amounted to 15 
out of the 25, and in all of them, with one exception, death occurred 
before the fourteenth day, often on the second or third. The reason of 
this seems to be that in the former time is required to admit of degener- 
ative changes taking place in the deposited fibrin leading to separation 
of an embolus, while in the latter the thrombosis corresponds in time, 
and to a great extent no doubt also in cause, to the original peripheral 
thrombosis from which in the former the embolus was derived. Many 
cases I have since collected illustrate the same rule in a very curious and 
instructive way. 

Another clinical fact I have observed points to the same conclusion. 
In one or two cases distinct signs of pulmonary obstruction have shown 
themselves without proving immediately fatal, and shortly afterward 
peripheral thrombosis, as evidenced by phlegmasia dolens of one extrem- 
ity, has commenced. Here the peripheral thrombosis obviously followed 
the central, both being produced by Identical causes, and the order of 
events necessary to uphold the purely embolic theory was reversed. 

I hold, then, that those who deny the possibility of spontaneous i 
ulation in the heart and pulmonary arteries do so on insufficient 
grounds, and that we may consider it to be an occurrence, rare no 
doubt, but still sufficiently often met with, and certainly of sufficient 
importance, to merit very careful study. 

History. — Dr. Charles D. Meigs of Philadelphia was • of the first 

to direct attention to spontaneous coagulation of the blood in the righl 
side of the heart and pulmonary arteries as a cause of Budden death in 
the puerperal state. The occurrence itself, however, has been carefully 
studied by Paget, whose paper was published in L855, four years l- fore 

1 Lancet, L867. 
40 



626 THE PUERPERAL STATE. 

Meigs wrote on the subject. 1 It is true that none of Paget's cases hap- 
pened after delivery, but he none the less clearly apprehended the nature 
of the obstruction. In 1855, Hecker 2 attributed the majority of these 
cases to embolism proper ; and since that date most authors have taken 
the same view, believing that spontaneous coagulation only occurs in 
exceptional cases, such as those in which, on account of some obstruc- 
tion in the lung or in the debility of the last few hours before death, 
coagula form in the smaller ramifications of the pulmonary arteries and 
gradually creep backward toward the heart. 

Symptoms of Pulmonary Obstruction. — The symptoms can hardly be 
mistaken, and there seems to be no essential difference between the 
symptomatology of spontaneous and embolic obstructions, so that the 
same description will suffice for both. In a larger proportion of cases 
the attack comes on with an appalling suddenness which forms one of its 
most striking characteristics. Nothing in the condition of the patient 
need have given rise to the least suspicion of impending mischief, when 
all at once an intense and horrible dyspnoea comes on ; she gasps and 
struggles for breadth, tears off the coverings from her chest in a vain 
endeavor to get more air, and often dies in a few minutes, long before 
medical aid can be had, with all the symptoms of asphyxia. The mus- 
cles of the face and thorax are violently agitated in the attempt to oxy- 
genate the blood, and an appearance closely resembling an epileptic con- 
vulsion may be presented. The face may be either pale or deeply 
cyanosed. Thus in one case I have elsewhere recorded, which was an 
undoubted example of true embolism, Mr. Pedler, the resident accou- 
cheur at King's College Hospital, who was present during the attack, 
writes of the patient : 3 " She was suffering from extreme dyspnoea, the 
countenance was excessively pale, her lips white, the face generally 
expressing deep anxiety." In another, which was probably an example 
of spontaneous thrombosis 4 occurring on the twelfth day after delivery, 
it is stated, " The face had assumed a livid purple hue, which was so 
remarkable as to attract the attention both of the nurse and of her 
mother, who was with her." The extreme embarrassment of the circu- 
lation is shown by the tumultuous and irregular action of the heart in 
its endeavor to send the venous blood through the obstructed pulmonary 
arteries. Soon it gets exhausted, as shown by its feeble and fluttering 
beat. The pulse is thread-like and nearly imperceptible, the respirations 
short and hurried, but air may be heard entering the lungs freely. The 
intelligence during the struggle is unimpaired, and the dreadful con- 
sciousness of impending death adds not a little to the patient's sufferings 
and to the terror of the scene. Such is an imperfect account of the 
symptoms gathered from a record of what has been observed in fatal 
cases. It will be readily understood why, in the presence of so sudden 
and awful an attack, symptoms have not been recorded with the accu- 
racy of ordinary clinical observation. 

Is Recovery Possible f — A question of great practical interest, which 
has been entirely overlooked by writers on the subject, is, Have we any 

1 Medico-Chir. Trans., vol. xxvii. p. 162, and vol. xxviii. p. 352; Philadelphia Med- 
ical Examiner, 1849. 2 Deutsche klinicke, 1855. 
3 Brit. Med. Journ., March 27, 1869. 4 Obst. Trans., vol. xii. p. 194. 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 627 

ground for supposing that there is a possibility of recovery after symp- 
toms of pulmonary obstruction have developed themselves ? That Buch 
a result must be of extreme rarity is beyond question, but I have little 
doubt that in some few cases, entirely inexplicable on any other hypoth- 
esis, life is prolonged until the coagulum is absorbed and the pulmon- 
ary circulation restored. In order to admit of this it is of course essen- 
tial that the obstruction be not sufficient to prevent the passage of a 
certain quantity of blood to the lungs to carry on the vital functions. 
The history of many cases tends to show that the obstructing clol was 
present for a considerable time before death, and that it was only when 
some sudden exertion was made, such as rising from bed or the like, 
calling for an increased supply of blood which could not pass through 
the occluded arteries, that fatal symptoms manifested themselves. This 
was long ago pointed out by Paget, 1 who says : "The case proves that 
in certain circumstances a great part of the pulmonary circulation may 
be arrested in the course of a week (or a few days more; or less) without 
immediate danger to life or any indication of what had happened;" 
and, after referring to some illustrative cases, " Yet in all these cases the 
characters of the clots by which the pulmonary arteries were obstructed 
showed plainly that they had been a week or more in the process of for- 
mation." If we admit the possibility of the continuance of life for a 
certain time, we must, I think, also admit the possibility, in a few rare 
cases, of eventual complete recovery. What is required is time for the 
absorption of the clot. In the peripheral venous system coagula are 
constantly removed by absorption. So strong, indeed, is the tendency 
to this that Humphrey observes with regard to it, " It appear- that the 
blood is almost sure to revert to its natural channel in process of time."* 
If, then, the obstruction be only partial, if sufficient blood pass to keep 
the patient alive, and a sudden supply of oxygenated blood is noi 
demanded by any exertion which the embarrassed circulation is unable 
to meet, it is not inconceivable that the patient may live until the 
obstruction is removed. 

Illustrative Cases. — Such I believe to be the only explanation of cer- 
tain cases, some of which on any other hypothesis ii la i i » 1 1 >< > — i 1 » ] » * to 
understand. The symptoms are precisely those of pul nary obstruc- 
tions, and the description I have given above may be applied t<> them in 
every particular ; and, after repeated paroxysms, each of which seems to 
threaten immediate dissolution, an eventual recovery takes place. 
What, then, I am entitled to ask, can the condition !><• if not thai which 
I suggest? As the question I am considering has never, so for as I am 
aware, been treated of by any other writer, I may be permitted !<• 
state, very briefly, the facts of one or two of the cases "ii which I 
found my argument, some of which I have already published in detail 
elsewhere : 

K. II., delicate young lady. Labor easy. First child. Profuse post \ 
hemorrhage. Did well until the seventh day, during the whole of which sn< 
weak. Same day an alarming attack of dyspnoea came on, For several days she 
remained in a very critical condition, tic Bligntesi exertion bringing on the attacks, 
A slight blowing murmur heard for a few days al tli<- base of the heart, and then 

1 Op. cit., p. 358. ] ! : -'' : I ' vii - 1' ' '• 



628 THE PUERPERAL STATE. 

disappeared. For two months patient remained in the same state. As long as she 
was in the recumbent position she felt pretty comfortable, but any attempt at sit- 
ting up in bed or any unusual exertion immediately brought on the embarrassed 
respiration. During all this time it was found necessary to administer stimulants 
profusely to ward off the attacks. Eventually the patient recovered completely. 

Q. F., set. 44. Mother of twelve children. Confined on July 6. On the eleventh 
day she went to bed feeling well. There was no swelling or discomfort of any kind 
about the lower extremities at this time. 'About half-past 3 a. m. she was sitting 
up in bed, when she was suddenly attacked with an indescribable sense of oppres- 
sion in the chest, and fell back in a semi-unconscious state, gasping for breath. 
She remained in a very critical condition, with the same symptoms of embarrassed 
respiration, for three days, when they gradually passed away. Two days after the 
attack phlegmasia dolens came on, the leg swelled, and remained so for several 
months. 

This case is an example of the fact I have already referred to, of 
phlegmasia dolens coming on after the symptoms of pulmonary obstruc- 
tion had manifested themselves ; the inference being that both depended 
on similar causes operating on two distinct parts of the circulatory 
system. 

C. H., set 24. Confined of her first child on August 20, 1867. Thirty hours 
after delivery she complained of great weakness and dyspnoea. This was alleviated 
by the treatment employed, but on the ninth day, after making a sudden exertion, 
the dyspnoea returned with increased violence, and continued unabated until I saw 
the patient on September 4, fourteen days after her confinement. The following 
are the notes of her condition, made at the time of the visit: " I found her sitting 
on the sofa propped up with pillows, as she said she could not breathe in the 
recumbent position. The least excitement or talking brought on the most aggra- 
vated dyspnoea, which was so bad as to threaten almost instant death. Her suffer- 
ings during these paroxysms were terrible to witness. She panted and struggled 
for breath, and her chest heaved with short, gasping respirations. She could not 
even bear any one to stand in front of her, waving them away with her hand and 
calling for more air. These attacks were very frequent, and were brought on by 
the most trivial causes. She talked in a low, suppressed voice, as if she could not 
spare breath for articulation. On auscultation air was found to enter the lungs 
freely in every direction, both in front and behind. Immediately over the site of 
the pulmonary arteries there was a distinct harsh, rasping murmur, confined to a 
very limited space and not propagated either upward or downward. The heart- 
sounds were feeble and tumultuous." These symptoms led me to diagnose pul- 
monary obstruction, and I of course gave a most unfavorable prognosis, but to my 
great surprise the patient slowly recovered. I saw her again six weeks later, vrhen 
her heart-sounds were regular and distinct and the murmur had completely disap- 
peared. 

E. E., set. 42, was confined for the first time on November 5, 1873, in the sixth 
month of utero-gestation. She had severe post-partum hemorrhage, depending on 
partially-adherent placenta, which was removed artificially. She did perfectly well 
until the fourteenth day after delivery, when she was suddenly attacked with 
intense dyspnoea, aggravated in paroxysms. Pulse pretty full, 130, but distinctly 
intermittent. Air entered lungs freely. The heart's action was fluttering and 
irregular, and at the juncture of the fourth and fifth ribs with the sternum there 
was a loud blowing, systolic murmur. This was certainly non-existent before, as 
the heart had been carefully auscultated before administering chloroform during 
labor. For two days the patient remained in the same state, her death being 
almost momentarily expected. On the 21st — that is, two days after the appearance 
of the chest symptoms — phlegmasia dolens of a severe kind developed itself in the 
fight thigh and leg. She continued in the same state for many days, lying more 
or less tranquilly, but having paroxysms of the most intense apncea, varying from 
two to six or eight in the twenty-four hours. No one who saw her in one of these 
could have expected her to live through it. Shortly after the first appearance of 
the paroxysms it was observed that the cellular tissue of the neck and part of the 



PUERPERAL VENOUS THROMBOSIS AND EMBOLISM. 629 

face became swollen and oedematous, giving an appearance not unlike that of 
phlegmasia dolens. The attacks were always relieved by stimulants. These she 
incessantly called for, declaring that she felt they kept her alive. During all this 
time the mind was clear and collected. The pulse varied from 1 LO to 130; respira- 
tions about 60; temperature 101° to 102.5°. By slow degrees the patient seemed 
to be rallying. The paroxysms diminished in number, and after December 1st she 
never had another, and the breathing became free and easy. The pulse fell to v u 
and the cardiac murmur entirely disappeared. The patient remained, however, 
very weak and feeble, and the debility seemed to increase. Toward the second 
week in December she became delirious, and died, apparently exhausted, without 
any fresh chest symptoms, on the 19th of that month. No post-mortem examina- 
tion was allowed. 

I have narrated this case, although it terminated fatally, because I 
hold it to be one of the class I am considering. The death was certainly 
not due to the obstruction, all symptoms of which had disappeared, but 
apparently to exhaustion from the severity of the former illness. It 
illustrates, too, the simultaneous appearance of symptoms of pulmonary 
obstruction and peripheral thrombosis. The swelling of the neck was 
a curious symptom which has not been recorded in any other cases, and 
may possibly be a further proof of the analogy between this condition 
and phlegmasia dolens. 

Such Cases can only Depend on Pvlmonary Obstruction. — Now, it 
may, of course, be argued that these cases <1<> not prove my thesis, inas- 
much as I only assume the presence of a coagulum. But I may fairly 
ask in return, What other condition could possibly explain the symp- 
toms? They are precisely those which are noticed in death from un- 
doubted pulmonary obstruction. Xo one seeing one of them, or even 
reading an account of the symptoms, while ignorant of tin- result, could 
hesitate a single instant in the diagnosis. Surely, then, the inference is 
fair that they depended on the same cause. In the very nature of things 
my hypothesis cannot be verified by post-mortem examination, but there 
is at least one case on record in which, after similar symptoms, a clot 
was actually found. The case is related by Dr. Richardson. 1 It was 
that of a man who for weeks had symptoms precisely similar t<> those 
observed in the cases I have narrated. In <>ne of his agonizing stm 
for breath he died, and after death it was found 4> that a fibrinous band, 
having its hold in the ventricle, extended into the pnliii.»u:n\ artery." 
This observation proves to a certainty that life may continue for weeks 
after deposition of a coagulum; and, moreover, tin- condition was pre- 
cisely what we should anticipate, since, of course, the obstructing coagu- 
lum must necessarily be -mall, otherwise the vital functions would be 
immediately arrested. 

Cardkuo Murmurs in Pulmonary Obstruction. — There i- ;i symptom 
noted in two of the above cases, and to ;i less extent in a third, which 
has not been mentioned in any account of fatal cases occurring after 
delivery — viz. a murmur over the site of the pulmonary arteries. It is 
a sign we should naturally expect, and very possibly it would be met 
with in fatal cases if attention were particularly directed to the point 
In both these instances it was exceedingly well marked, and in huth it 
entirely disappeared when the symptoms abated. The probability of 
1 Clinical Essays ]». 224 >■ 



630 THE PUERPERAL STATE. 

such a murmur being audible in cases of thrombosis of the pulmonary 
artery has been recognized by one of our highest authorities in cardiac 
disease, who actually observed it in a non-puerperal case. In the last 
edition of his work on diseases of the heart Dr. Walshe l says : " The 
only physical condition connected with the vessel itself would probably 
be systolic basic murmur following the course of the pulmonary main 
trunk and of its immediate divisions to the left and right of the ster- 
num. This sign I most certainly heard in an old gentleman whose life 
was brought to a sudden close, in the course of an acute affection, by 
coagulation in the pulmonary artery, and to a moderate extent in the 
right ventricle." 

Similar cases have probably been overlooked or misinterpreted. Many 
seem to have been attributed to shock, in the absence of a better explana- 
tion — a condition to which they bear no kind of resemblance. 

Causes of Death. — The precise mode of death in pulmonary obstruc- 
tion, whether dependent on thrombosis or embolism, has given rise to 
considerable difference of opinion. Virchow attributes it to syncope 2 
depending on stoppage of the cardiac contraction. Panum, 3 on the other 
hand, contests this view, maintaining that the heart continues to beat 
even after all signs of life have ceased. Certainly, tumultuous and 
irregular pulsations of the heart are prominent symptoms in most of 
the recorded cases, and are not reconcilable with the idea of syncope. 
Panum's own theory is that death is the result of cerebral anaemia. 
Paget seems to think that the mode of death is altogether peculiar, in 
some respects resembling syncope, in others anaemia. Bertin, who has 
discussed the subject at great length, attributes the fatal result purely to 
asphyxia. The condition, indeed, is in all respects similar to that state, 
the oxygenation of the blood being prevented, not because air cannot get 
to the blood, but because blood cannot get to the air. The symptoms 
also seem best explained by this theory : the intense dyspnoea, the terri- 
ble struggle for air, the preservation of intelligence, the tumultuous 
action of the heart, are certainly not characteristic either of syncope or 
anaemia. 

Post-mortem Appearances of Clots. — The anatomical character of the 
clots seems to vary considerably. Ball, by whom they have been most 
carefully described, believes that they generally commence in the smaller 
ramifications of the arteries, extending backward toward the heart and 
filling the vessels more or less completely. Toward its cardiac extremity 
the coagulum terminates in a rounded head, in which respect it resembles 
those spontaneously formed in the peripheral veins. It is non-adherent 
to the coats of the vessels, and the blood circulates, when it can do so 
at all, between it and the vascular walls. Such clots are white, dense, 
and of a homogeneous structure, consisting of layers of decolorized 
fibrin, firm at the periphery, where the fibrin has been most recently 
deposited, and softened in the centre, where amylaceous or fatty degen- 
eration has commenced. Ball maintains that if the coagulum have com- 
menced in the larger branches of the arteries, it must have first begun 
in the ventricle and extended into them. According to Humphrey, the 

1 Walshe, On Diseases of the Heart, 4th ed., 1873. 

2 Qesamm. Abhandl, 1862, p. 316. 3 Virchow' s Archiv, 1863. 



PUERPERAL VENOUS THROMBOSIS AXD EMBOLISM. 631 

same changes take place in pulmonary as in peripheral thrombi, and they 
may become adherent to the walls of the vessels or converted into threads 
or bands. When the obstruction is due to embolism, provided the case 
is a well-marked one and the embolus of some size, the appearances pre- 
sented are different. We have no longer a laminated and decolorized 
coagulum with a rounded head, similar to a peripheral thrombus. The 
obstruction in this case generally takes place at the point of bifurcation 
of the artery, and we there meet with a grayish-white mass, contrasting 
remarkably with the more recently-deposited fibrin before and behind it. 
It may be that the form of the embolus shows that it has recently been 
separated from a clot elsewhere; and in many cases it has been possible 
to fit the travelled portion to the extremity of the clot from which it 
has been broken. We may also, perhaps, find that the embolus lias 
undergone an amount of retrograde metamorphosis corresponding with 
that of the peripheral thrombus from which we suppose it t<» have come, 
but differing from that of the more recently-deposited fibrin around it. It 
must be admitted, however, that the anatomical peculiarities of the co- 
agula will by no means always enable us to trace them to their true 
origin. In many cases emboli may escape detection from their smallness 
or from the quantity of fibrin surrounding them. 

Treatment. — But few words need be said as to the treatment <>f pul- 
monary obstruction. In a large majority of cases the fatal result so 
rapidly follows the appearance of the symptoms that no time i- given US 
even to make an attempt to alleviate the patient's Bufferings. Should 
we meet with a case not immediately fatal, it seems that there are but 
two indications of treatment affording the slightest rational ground of 
hope : 

1. To keep the patient alive by the administration of stimulant — 
brandy, ether, ammonia, and the lik< — to be repeated at intervals corre- 
sponding to the intensity of the paroxysms and the results produced. 
In the cases I have above narrated in which recovery ensued tlii- took 
the place of all other medication. Possibly leeches or diy cupping i«- 
the chest might prove of some service in relieving the circulation. 

2. To enjoin the most absolute and complete repose. Theobiect of 
this is evident. The only chance for the patient seems t«- be that the 
vital functions should be' carried on until ili<- coaeulum ha- been ab- 
sorbed, or at least until it has been so much lessened in -!/<• Bfl i" admit 
of blood passing it to the lungs. The slightest movements maj 

rise to a fatal paroxysm of dyspnoea from the increased supply or 
genated blood required. It must not be forgotten that in alarge pro- 
portion of cases death immediately followed Borne exertion in itself triv- 
ial, such as risingout of bed. Too much attention, then, ca t be 

to this point. The patient should be absolutely still ; she Bhould b 
with abundance of fluid food, Buch as milk, strong soups, and the like, 
and should on no account be permitted to raise herself in bed orattempt 
the slightest muscular exertion, [f we are fortunate enough to 
with a case apparently tending to recovery, these precautions must be 
carried on long after the severity of the Bymptoms haa lessened, 
moment's imprudence may suffice to bring them back in all their 
inal intensity. 



632 THE PUERPERAL STATE. 

Berlin, 1 indeed, recommends a system of treatment very different from 
this. In the vain hope that the violent effort induced may cause the dis- 
placement of the impacted embolus (to which alone he attributes pul- 
monary obstruction) he recommends the administration of emetics. 
Few, I fancy, will be found bold enough to attempt so hazardous a plan 
of treatment. 

Various drugs have been suggested in these cases. Richardson 2 
recommended ammonia, a deficiency of which he at that time believed 
to be the chief cause of coagulation. He has since advised that liquor 
ammonia? should be given in large doses, 20 minims every hour, in the 
hope of causing solution of the deposited fibrin ; and he has stated that 
he has seen good results from the practice. Others advise the admin- 
istration of alkalies, in the hope that they may favor absorption. The 
best that can be said for them is that they are not likely to do much 
harm. 

Puerperal Pleuropneumonia. — This is perhaps the best place to men- 
tion an important but little-understood class of cases which I believe to 
be less uncommon than is generally supposed. I refer to severe pleuro- 
pneumonia occurring in connection with the puerperal state, but not dis- 
tinctly associated with septicaemia. Two carefully-observed cases of this 
kind are recorded by MacDonald, occurring in his practice ; I myself 
have met with three very marked examples within the past three years, 
one of which proved fatal, the other two giving rise to most serious 
illness, from which the patient recovered with difficulty. 

Peculiarities of these Cases. — So far as my own observation goes, there 
are marked peculiarities in such cases which clearly differentiate them from 
the ordinary course of pneumonia. The onset is sudden and unconnected 
with exposure to cold or other cause of lung disease ; there is no definite 
crisis, but a continuous pyrexia, of moderate intensity, lasting a variable 
time ; and the physical signs differ from those of ordinary pneumonia. 

Physical Signs. — In MacDonald's case, as well as in my own, they 
were peculiar in this respect, that there was very slight crepitation, 
marked rusty sputum, and a wooden dulness, much more intense than 
in ordinary pneumonia, extending over a large lung-space, with a very 
slight entrance of air into the lung-tissue. It is also remarkable that a 
very large proportion of the cases was associated with phlegmasia dolens. 
Thus, it existed in one of MacDonald's two cases, and in two out of my 
own three. Like phlegmasia dolens, moreover, the disease generally 
commenced some weeks after delivery ; my own cases, for example, 
occurred respectively fifteen, twenty-eight, and thirty-five clays after 
labor. It is difficult to believe that there is not some connection between 
these two conditions, and there is much in their peculiar history to lead 
to the belief that such forms of lung disease depend, in fact, on throm- 
botic or embolic obstruction of the minute branches of the pulmonary 
arteries, caused by conditions similar to those which have produced the 
phlebitic obstructions in the lower extremities. In the absence of careful 
post-mortem examination this hypothesis is clearly not susceptible of 
proof. MacDonald, while admitting that "a limited thrombosis of 
the pulmonary arteries would no doubt explain the facts of the cases/' 

1 Op. cil, p. 393. l Heart Disease during Pregnancy, p. 209. 



PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. 633 

is rather inclined to " seek the chief explanation of their occurrence in 
the alterations which the pregnant and puerperal conditions impress 
upon the blood and the blood-vascular system." 

I confess that, to my mind, the former hypothesis is not only the most 
definite, but the one which most readily explains all the peculiarities of 
these cases. I cannot, however, do more than suggest it, in the hope 
that further observations, and especially carefully-conducted autopsies, 
may throw some light on this obscure and little-studied subject. 

Treatment. — As regards treatment, it is obvious that it must be con- 
ducted on general principles, carefully avoiding over-severe measures, 
and supporting the patient through a trial to the system that must ne- 
cessarily be severe. 



CHAPTER VII. 

PUERPERAL ARTERIAL THROMBOSIS AXD EMBOLISM. 

The same condition of the blood which so strongly predisposes to 
coagulation in the vessels through which venous blood circulates tends 
to similar results in the arterial system. These, however, are by no 
means so common, and do not, as a rule, lead to such important conse- 
quences. The subject has been but little studied, and almost all our 
knowledge of it is derived from a very interesting essay by Sir James 
Simpson. 1 As I have devoted so much space to the consideration of 
venous thrombosis and embolism, I shall but briefly consider the effects 
of arterial obstruction. 

Causes. — In a considerable number of recorded cases the obstruction 
has resulted from the detachment of vegetations deposited on the cardiac 
valves, the result of endocarditis, either produced by antecedent rheuma- 
tism or as a complication of the puerperal state. Sometimes the obstruc- 
tion seems to depend on some general blood-dyscrasia, similar to that pro- 
ducing venous thrombosis, or on some local change in the artery itselL 
Thus, Simpson records a case apparently produced by local arteritis, 
which caused acute gangrene of both local extremities, ending fatally in 
the third week after delivery. In other cases it has been attributed to 
coagulation following spontaneous laceration and corrugation oi the 
internal coat of the artery. 

Symptoms. — The symptoms of puerperal arterial obstruction must 01 
com--;' vary with the particular arteries affected. Those with the ob- 
struction of which we are most familiar are the cerebral, the brachial, 
and the femoral. The effects produced must also be modified by the 
size of the embolus and the more or less complete obstruction it pro- 
duces. Tims, for example, if the middle cerebral artery be blocked tip 
entirely, the functions of those portions of the brain supplied by it will 
be more or Less completely arrested, and hemiplegia of the opposite side 

1 Selected ObsL Work^ v<4. i. p, 528. 



634 THE PUERPERAL STATE. 

of the body, followed by softening of the brain-texture, will probably 
result. If the nervous symptoms be developed gradually or increase in 
intensity after their first appearance, it may be that an obstruction, at 
first incomplete, has increased by the deposition of fibrin around it. So 
the occasional sudden supervention of blindness, with destruction of the 
eyeball — cases of which are recorded by Simpson — not improbably de- 
pends on the occlusion of the ophthalmic artery, the function of the organ 
depending on its supply through the single artery. The effects of obstruc- 
tion of the visceral arteries in the puerperal state are entirely unknown, 
but it is far from unlikely that further investigation may prove them to 
be of great importance. In the extremities arterial obstruction produces 
effects which are well marked. They are classified by Simpson under 
the following heads: 1. Arrest of pulse below the site of obstruction. — 
This has been observed to come on either suddenly or gradually, and if 
the occlusion be in one of the large arterial trunks, it is a symptom which 
a careful examination will readily enable us to detect. 2. Increased force 
of pulsation in the arteries above the seat of obstruction. 3. Fall in the 
temperature of the limb. — This is a symptom which is easily appreciable 
by the thermometer, and when the main artery of the limb is occluded 
the coldness of the extremity is well marked. 4. Lesions of motor and 
sensory functions, paralysis, neuralgia, etc. etc. — Loss of power in the 
affected limb is often a prominent symptom, and when it comes on sud- 
denly, and is complete, the main artery will probably be occluded. It 
may be diagnosed from paralysis depending on cerebral or spinal causes 
by the absence of head-symptoms, by the history of the attack, and by 
the presence of other indications of arterial obstruction, such as loss of 
pulsation in the artery, fall of temperature, etc. The sensory functions 
in these cases are generally also seriously disturbed — not so much by loss 
of sensation as by severe pain and neuralgia. Sometimes the pain has 
been excessive, and occasionally it has been the first symptom which 
directed attention to the state of the limb. 5. Gangrene below or beyond 
the seat of arterial obstruction. — Several interesting cases are recorded in 
which gangrene has followed arterial obstruction. Generally speaking, 
gangrene will not follow occlusion of the main arterial trunk of an 
extremity, as the collateral circulation becomes soon sufficiently devel- 
oped to maintain its vitality. In many of the cases either thrombi have 
obstructed the channels of collateral circulation as well, or the veins of 
the limb have also been blocked up. When such extensive obstructions 
occur, they obviously cannot be embolic, but must depend on a local 
thrombosis traceable to some general blood-dyscrasia depending on the 
puerperal state. 

Treatment. — Little can be said of such cases as to the treatment, which 
must vary with the gravity and nature of the symptoms in each. Beyond 
absolute rest (in the hope of eventual absorption of the thrombus or em- 
bolus), generous diet, attention to the general health of the patient, and 
sedative applications to relieve the local pain, there is little in our power. 
Should gangrene of an extremity supervene in a puerperal patient, the 
case must necessarily be wellnigh hopeless. Simpson, however, records 
one instance in which amputation was performed above the line of 
demarcation, the patient eventually recovering. 



CAUSES OF SUDDEX DEATH DURIXG LABOR. 635 



CHAPTER VIII. 

OTHER CAUSES OF SUDDEN DEATH DURING LABOR AND THE 
PUERPERAL STATE. 

Various Causes of Sudden Death. — A large number of the cases in 
which sudden death occurs during or after delivery find their explana- 
tion, as I have already pointed out, in thrombosis or embolism of the 
heart and pulmonary arteries. Probably many cases of the so-called 
idiopathic asphyxia were, in fact, examples of this accident, the true 
nature of which had been misunderstood. Besides these, there are do 
doubt many other conditions which may lead to a suddenly fatal result 
in connection with parturition. 

Some of these are of an organic, others of a functional, nature. 

Organic Causes. — Among the former may be mentioned cases in which 
the straining efforts of the second stage of labor have produced death in 
patients suffering from some pre-existent disease of the heart Rupture 
of that organ has probably occurred from fatty degeneration of its walls. 
Dehous 1 narrates an instance in which the efforts of labor caused the 
rupture of an aneurism. Another case, from interference with the action 
of the heart in a patient who had pericardial effusion, is narrated by 
Banisbotham. Dr. Devilliers relates an instance occurring in a young 
woman during the second stage of labor. The heart was found to be 
healthy, but the lungs were intensely congested and blood was exten- 
sively extravasated all through their texture. This was probably caused 
by pulmonary congestion and apoplexy, produced by the severe -train- 
ing efforts. Many eases from effnsion of blood into the brain-substance 
or on its surface are on record, no doubt in patients who, from arterial 
degeneration or other causes, were predisposed to apoplectic effusions. 
The so-called apoplectic convulsions, formerly described in most works 
on obstetrics a- a variety of puerperal convulsions, are evidently nothing 
more than apoplexy coming <»:i during or after labor. Ajs regards their 
pathology, they do not seem to differ from ordinary cases of apoplexy in 
the non-pregnant condition. One example is recorded of death which 
was attributed to rupture of the diaphragm from excessive action in the 
second stage. 

Functional ('ousts. — Among the causes "f death which cannot be 
traced t<> some distinct organic lesion may be classed cases of syncope, 
shock, and exhaustion. Many instances of this kind are recorded. Thus, 
in some women of susceptible nervous organization the severity <-i the 
suffering appears to bring on a condition similar t<> that produced by 
excessive shock or exhaustion, which ha- not (infrequently proved fatal. 
Several examples of tin- kind have been cited by McClintock. It is 
also not unlikely that sudden syncope sometimes produces ;i fetal result 
during or after labor. Most cases of death otherwise inexplicable used 

1 Dehous, Sur lea M'»-t.< .<nf>it>s. I ' 



636 THE PUERPERAL STATE. 

to be referred to this cause ; but accurate autopsies were seldom made, 
and even when they were — the important effects of pulmonary coagula 
being unknown — it is more than probable that the true cause of death 
was overlooked. It has been supposed that the sudden removal of 
pressure from the veins of the abdomen by the emptying of the gravid 
uterus after delivery may favor an increased afflux of blood into the 
lower parts of the body, and thus tend to an anaemic condition of the 
brain and the production of syncope. However this may be, the possi- 
bility of its occurrence, and its manifest danger in a recently-delivered 
woman, are sufficient reasons for enforcing the recumbent position after 
labor is over. In some of the cases the syncope was evidently produced 
by the patient's suddenly sitting upright. 

Death from Air in the Veins. — Some cases of sudden death immedi- 
ately after labor seem to be due to the entrance of air into the veins. 
Six examples are cited by McClintock which were probably due to this 
cause. La Chapelle relates two. An interesting case is related by M. 
Lionet. 1 In this the patient died five and a half hours after an easy and 
natural labor, the chief symptoms being extreme pallor, efforts at vomit- 
ing, and dyspnoea. Air was found in the heart and in the arachnoid 
veins. There can be no question that the uterine sinuses after delivery 
are nearly as well adapted as the veins of the neck for allowing the 
entrance of air. They are firmly attached to the muscular walls of the 
uterus, so that they gape open when that organ is relaxed, and it is easy 
to understand how air might enter. Indeed, in the post-mortem exam- 
ination in one of the cases occurring in the practice of Mme. La Chapelle 
it is stated that " the uterine sinuses opened in the interior of the uterus 
by large orifices (one line and a half in diameter), through which air 
could readily be blown as far as the iliac veins, and vice versa. 7 ' The 
condition of the uterus after delivery also enables the air to have ready 
access to the mouths of the sinuses, for the alternate relaxation and con- 
traction of the uterus occurring after the placenta is expelled would tend 
to draw in the air as by a suction-pump. Hence an additional reason 
for insisting on firm contraction of the uterus, as this will lessen the risk 
of this accident. 

Cause of Death in such Cases. — The precise mechanism of death 
from air in the veins has been a subject of dispute among pathologists. 
By Bichat 2 it was referred to anaemia and syncope from want of blood 
in the vessels of the brain, which are occupied by air. Nysten 3 attrib- 
uted it to distension of the cavities of the heart by rarefied air, produ- 
cing paralysis of its wail ; Leroy, to a stoppage of the pulmonary circu- 
lation, and consequent want of proper blood-supply to the left heart ; 
while Leroy d'Etoilles thought it might depend on any of these causes 
or a combination of all of them. These and many other hypotheses on 
the subject have been advanced, to all of which serious objection could 
be raised. The most recent theory is one maintained by Virchow and 
Oppolzer, 4 and more recently by Feltz, which attributes the fatal results 

1 Dehous, op. cit., p. 58. 2 Recherches sur la Vie et la 3 fort, 1 853. 

3 Nysten, Recherches de Phys. et Chem. Path., 1811. 

4 Casuist ics des Embolies; Wiener Med. Woeh., 1863; Des Embolies capillaires, 1868; 
and op. cit., p. 115. 



PERIPHERAL VENOUS THROMBOSIS. 637 

to impaction of the air-globules in the lesser divisions of the pulmonary 
arteries, where they form gaseous emboli, and cause death exactly in the 
same way as when the obstruction depends on a fibrinous embolus. The 
symptoms observed in fatal cases closely correspond to those of pulmo- 
nary obstruction, and it is not unlikely that some cases attributed to other 
causes may really depend on the entrance of air through the uterine 
sinuses. Such, for example, was most probably the explanation of a cast' 
referred to by Dr. Graily Hewitt in a discussion at the Obstetrical 
Society. 1 Death occurred shortly after the removal of an adherent pla- 
centa, during which, no doubt, air could readily enter the uterine cavity. 
The symptoms — viz. " severe pain in the cardiac region, distress as re- 
gards respiration, and pulselessness " — are identical with those of pul- 
monary obstruction. Dr. Hewitt refers the death to shock, which cer- 
tainly does not generally produce such phenomena. 



CHAPTER IX. 



PERIPHERAL VENOUS THROMBOSIS (SYNS. : CRURAL PHLEBITIS; 
PHLEGMASIA DOLENS ; ANASARCA SEROSA; (EDEMA LACTEUM; 
MILK LEG, ETC.). 

Peripheral Thrombosis. — AVe now come to discuss the symptoms and 
pathology of the conditions associated with the formation of thrombi in 
the peripheral venous system, or rather in the veins of the lower extrem- 
ities, since too little is known of their occurrence in other parts to enable 
us to say anything on the subject. 

The most important of these is the well-known disease which under 
the name phlccpnasia dolens has attracted much attention and given rise 
to numerous theories as to its nature and pathology. In describing it 
as a local manifestation of a general blood-dyscrasia, and not as an essen- 
tia] local disease, I am making an assumption as to its pathology that 
many eminent authorities would not consider justifiable. I have, how- 
ever, already stated some of the reasons lor bo doing, and I Bhall shortly 
hope to show that this view is not incompatible with the most probable 
explanation of the peculiar state of the affected limb. 

Symptoms. — The firsl symptom which usually attracts attention is 
severe pain in some pari of the limb thai is about to be affected. The 
character of the pain varies in differenl cases. In some ii is extremely 
acute, and i< mosl fell in the neighborhood and along the course of the 
chief venous trunks. It may begin in the groin or hip ;in«l extend 
downward, or it may commence in the calf ana proceed upward toward 
the pelvis. The pain abates somewhal after swelling of the limb (which 
generally begins within twenty-four hours), bul it i- always ;< distressing 
symptom, and continues as long ;i- the acute stage of tne disease lasts. 
1 ObsteL Tram., vol. s. p. 28; 



638 * THE PUERPERAL STATE. 

The restlessness, want of sleep, and suffering which it produces are some- 
times excessive. Coincident with the pain, and sometimes preceding it, 
more or less malaise is experienced. The patient may for a day or two 
be restless, irritable, and out of sorts without any very definite cause, 
or the disease may be ushered in by a distinct rigor. Generally, there 
is constitutional disturbance, varying with the intensity of the case. The 
pulse is rapid and weak, 120 or thereabouts ; the temperature elevated 
from 101° to 102°, with an evening exacerbation. The patient is thirsty, 
the tongue glazed or white and loaded, the bowels are constipated. In 
some few cases, when the local affection is slight, none of these constitu- 
tional symptoms are observed. 

Condition of the Affected Limb. — The characteristic swelling rapidly 
follows the commencement of the symptoms. It generally begins in the 
groin, whence it extends downward. It may be limited to the thigh, or 
the whole limb, even to the feet, may be implicated. More rarely it com- 
mences in the calf of the leg, extending upward to the thigh and down- 
ward to the feet. The affected parts have a peculiar appearance which 
is pathognomonic of the disease. They are hard, tense, and brawny, of 
a shiny white color, and not yielding on pressure, except toward the 
beginning and end of the illness. The appearances presented are quite 
different from those of ordinary oedema. When the whole thigh is 
affected the limb is enormously increased in size. Frequently the ven- 
ous trunks, especially the femoral and popliteal veins, are felt obstructed 
with coagula, and rolling under the finger. They are painful when 
handled, and in their course more or less redness is occasionally observed. 
Either leg may be attacked, but the left more frequently than the right. 
There is a marked tendency for the disease to spread, and we often find, 
in a case which is progressing apparently well, a rise of temperature and 
an accession of febrile symptoms followed by the swelling of the other 
limb. 

Progress of the Disease. — After the acute stage has lasted from a week 
to a fortnight the constitutional disturbance becomes less marked, the 
pulse and temperature fall, the pain abates, and the sleeplessness and 
restlessness are less. The swelling and tension of the limb now begin 
to diminish, and absorption commences. This is invariably a slow process. 
It is always many weeks before the effusion has disappeared, and it may 
be many months. The limb retains for a length of time the peculiar 
loooden feeling, as Dr. Churchill terms it. Any imprudence, such as a 
too early attempt at walking, may bring on a relapse and fresh swelling 
of the limb. This gradual recovery is by far the most common termi- 
nation of the disease. In some rare cases suppuration may take place, 
either in the subcutaneous cellular tissue, the lymphatic glands, or even 
in the joints, and death may result from exhaustion. The possibility 
of pulmonary obstruction and sudden death from separation of an em- 
bolus have already been pointed out ; and the fact that this lamentable 
occurrence has generally followed some undue exertion should be borne 
in mind as a guide in the management of our patient. 

Period of Commencement. — The disease usually begins within a short 
time after delivery, rarely before the second week. In 22 cases tabu- 
lated by Dr. Robert Lee, 7 were attacked between the fourth and twelfth 



PERIPHERAL VENOUS THROMBOSIS. 639 

days, and 14 after the second week. Some cases have been described as 
commencing even months after delivery. It is questionable if these can 
be classed as puerperal, for it must not be forgotten that phlegmasia 
dolens is by no means necessarily a puerperal disease [or confined to the 
female sex]. There are many other conditions which may give rise to 
it, all of them, however, such as produce a septic and hyperinosed state 
of the blood, such as malignant disease, dysentery, phthisis, and the 
like. My own experience would lead me to think that cases of this 
kind are much more common than is generally believed. 

History and Pathology. — The disease has long attracted the attention 
of the profession. Passing over more or less obscure notices by II ipj De- 
rates, De Castro, and others, we find the first clear account in the writ- 
ings of Mauriceau, who not only gave a very accurate description of its 
symptoms, but made a guess at its pathology which was certainly more 
happy than the speculations of his successors : it is, he says, caused " by 
a reflux on the parts of certain humors which ought to have been evacu- 
ated by the lochia." Puzos ascribed it to the arrest of the secretion of 
milk and its extravasation in the affected limb. This theory, adopted 
by Levret and many subsequent writers, took a strong hold on both 
professional and public opinion, and to it we owe many of the names by 
which the disease is known to this day, such as (edema Lacteum, milk 
leg, etc. In 1784, Mr. White of Manchester attributed it to some mor- 
bid condition of the lymphatic glands and vessels of the affected parts ; 
and this or some analogous theory, such as that of rupture <>f* the 
lymphatics crossing the pelvic brim, as maintained by Tyre of Glou- 
cester, or general inflammation of the absorbents, as held by Dr. Ferrier, 
was generally adopted. 

Phlebitic Theory. — It was not until the year 1823 that attention was 
drawn to the condition of the veins. To Bouilland belongs the un- 
doubted merit of first pointing out that the veins of the affected limb 
were blocked up by coagula, although the fact had been previously 
observed by Dr. Davis of University College. Dr. Davis made dissec- 
tions of the veins in a fatal case, and found, as Bouillaud had done, that 
they were filled with coagula, which he assumed t<> be the results of 
inflammation of their coats ; hence the name of " crural phlebitis " w hich 
has been extensively adopted instead of phlegmasia dolens. Dr. Robert 
Lee did much to favor this view, and, finding that thrombi were present 
in the iliac and uterine as well as in the femoral veins, he eon- hided 
that the phlebitis commenced in the uterine branches of the hypogastric 
veins and extended downward to the femora!-. II«' pointed out thai 
phlegmasia dolens was not limited to the puerperal State, but that, when 
it did occur independently of it, other causes of uterine phlebitis were 
present, such as cancer of the os and cervii uteri. The inflammatory 
theory was pretty generally received, and even now i- considered by 
many to be a sufficient explanation of the disease, [ndeed, the lift that 
more or less thrombosis was always present rnw\<\ nm be denied; and on 
the supposition that thrombosis coula only !»<■ caused by phlebitis, as was 
long supposed to be the case, the inflammatory theory was the natural 
one. Before long, however, pathologists pointed "in that thrombosis 
was by no means necessarily, or even gen< rally, the result of inflamma- 



640 THE PUERPERAL STATE. 

tion of the vessels in which the clot wrs contained, but that the inflam- 
mation was more generally the result of the coagulum. 

Theory of its Dependence on Septic Causes. — The late Dr. Mackenzie 
took a prominent part in opposing the phlebitic theory. He proved by 
numerous experiments on the lower animals that inflammation is not 
sufficient of itself to produce the extensive thrombi which are found to 
exist, and that inflammation originating in one part of a vein is not apt 
to spread along its canal, as the phlebitic theory assumes. His con- 
clusion is, that the origin of the disease is rather to be sought in some 
septic or altered condition of the blood producing coagulation in the 
veins. Dr. Tyler Smith l pointed out an occasional analogy between the 
causes of phlegmasia dolens and puerperal fever, evidently recognizing 
the dependence of the former on blood-dyscrasia. " I believe," he says, 
" that contagion and infection play a very important part in the produc- 
tion of the disease. I look on a woman attacked with phlegmasia 
dolens as having made a fortunate escape from the greater dangers of 
diffuse phlebitis or puerperal fever." In illustration of this he narrates 
the following instructive history : "A short time ago a friend of mine 
had been in close attendance on a patient dying of erysipelatous sore 
throat with sloughing, and was himself affected with sore throat. Under 
these circumstances he attended, within the space of twenty-four hours, 
three ladies in their confinements, all of whom were attacked with phleg- 
masia dolens." 

View of Tilbury Fox. — The latest important contribution to the 
pathology of the disease is contained in two papers by Dr. Tilbury Fox, 
published in the second volume of the Obstetrical Transactions. He 
maintained that something beyond the mere presence of coagula in the 
veins is required to produce the phenomena of the disease, although he 
admitted that to be an important, and even an essential, part of the 
pathological changes present. The thrombi he believed to be produced 
either by extrinsic or intrinsic causes — the former comprising all cases 
of pressure by tumor or the like ; the latter, and the most important, 
being divisible into the heads of — 

1. True inflammatory changes in the vessels, as seen in the epidemic 
form of the disease. 

2. Simple thrombus, produced by rapid absorption of morbid fluid. 

3. Virus action and thrombus conjoined, the phlegmasia dolens itself 
being the result of simple thrombus, and not produced by diseased (in- 
flamed) coats of vessels ; the general symptoms the result of the general 
blood-state. 

He further pointed out that the peculiar swelling of the limbs cannot 
be explained by the mere presence of oedema, from which it is essentially 
different ; the white 'appearance of the skin, the severe neuralgic pain, 
and the persistent numbness indicating that the whole of the cutaneous 
textures, the cutis vera, and even the epithelial layer, are infiltrated with 
fibrinous deposit. He concluded, therefore, that the swelling is the 
result of oedema plus something else, that something being obstruction 
of the lymphatics, by which the absorption of effused serum is prevented. 
The efficient cause which produces these changes he believes to be, in the 
1 Tyler Smith, Manual of Obstetrics, p. 538. 



PERIPHERAL VENOUS THROMBOSIS. 641 

majority of cases, a septic action originating in the uterus, producing a 
condition similar to that in which phlegmasia dolens arises in the non- 
puerperal state. 

There is no doubt much force in Dr. Fox's arguments, and it may, I 
think, be conceded that obstruction of the veins, per »e, is not sufficient 
to produce the peculiar appearance of the limb. It is, moreover, certain 
that phlebitis alone is also an insufficient explanation not only of the 
symptoms, but even of the presence of thrombi so extensive as those 
that are found. The view which traces the disease solely to inflamma- 
tion or obstruction of lymphatics is purely theoretical, has no basis of 
facts to support it, and finds now-a-days no supporters. The experi- 
ments of Mackenzie and Lee, as well as the vastly increased knowledge 
of the causes of thrombosis which the researches of modern pathologists 
have given us, seem to point strongly to the view already stated, that 
the disease can only be explained by a general blood-dyscrasia depending 
on the puerperal state. It by no means follows that we arc to consider 
Dr. Fox's speculations as incorrect. It is far from improbable that the 
lymphatic vessels are implicated in the production of the peculiar swell- 
ing, only we are not as yet in a position to prove it. There is no inhe- 
rent improbability in the supposition that the same morbid state of the 
blood which produces thrombosis in the veins may also give rise t<» such 
an amount of irritation in the lymphatics as may interfere with their 
functions, and even obstruct them altogether. The essential and all- 
important point in the pathology of the disease, however, seems un- 
doubtedly to be thrombosis in the veins ; and the probability of there 
being some as yet undetermined pathological changes in addition to this 
by no means militates against the view I have taken of the intimate 
connection of the disease with other results of thrombosis in different 
vessels. 

Changes oomrring in the Thrombi, — The changes which take place in 
the thrombi all tend to their ultimate absorption. These have been 
described by various author- a- Leading to organization or suppuration. 
It is probable, however, that the appearances which have led t<> such a 
supposition are fallacious, and that they are really due to retrograde 
metamorphosis of the fibrin, generally of an amylaceous or fatty cha- 
racter. 

Detachment of Emboli. — The peculiarities of a clol thai mosl favor 
detachment of an embolus are such ;i shape as admits of ;i portion float- 
ing freely in the blood-current, by the force of which it i- detached and 
carried to its ultimate destination. When the accident has occurred it i- 
often possible to recognize the peripheral thrombus from which the em- 
bolus has separated, by the feci or its terminal extremity presenting a 
freshly-fractured end, instead <»f the rounded head natural to it. - 
detachment i- unlikely to occur, even when favored by the shape of the 
clot, unless sufficient time have elapsed after it- formation to admit of 
its softening and becoming brittle. The curious fad 1 have before men- 
tioned, of true puerperal embolism occurring in the large majority of 
cases only after the nineteenth day from delivery, fmd- a ready explana- 
tion in this theory, which it remarkably corroborato -. 

Treatment. — On the supposition that phlegmasia dolene was the result 

41 



642 THE PUERPERAL STATE. 

of inflammation of the veins of the aifected limb, an antiphlogistic course 
of treatment was naturally adopted. Accordingly, most writers on the 
subject recommend depletion, generally by the application of leeches 
along the course of the affected vessels. We are told that if the pain 
continue the leeches should be applied a second or even a third time. 
If we admit the septic origin of the disease, we must, I think, see the 
impropriety of such a practice. The fact that it occurs in a large major- 
ity of cases in patients of a weakly and debilitated constitution, often in 
women who have suffered from hemorrhage, is a further reason for not 
adopting this routine custom. If local loss of blood be used at all, it 
should be strictly limited to cases in which there is much tenderness and 
redness across the course of the veins, and then only in patients of 
plethoric habits and strong constitution. Cases of this kind will form 
a very small minority of those coming under our observation. 

Over-active Treatment {Inadvisable. — What has been said of the path- 
ology of the affection tends to the conclusion that active treatment of 
any kind in the hope of curing the disease is likely to be useless. Our 
chief reliance must be on time and perfect rest, in order to admit of the 
thrombi and the secondary effusion being absorbed, while we relieve 
the pain and other prominent symptoms and support the strength and 
improve the constitution of the patient. 

Relief of Pain, etc. — The constant application of heat and moisture to 
the affected limb will do much to lessen the tension and pain. Wrap- 
ping the entire limb in linseed-meal poultices, frequently changed, is one 
of the best means of meeting this indication. If, as is sometimes the 
case, the weight of the poultices be too great to be readily borne, we 
may substitute warm flannel stupes covered with oiled silk. Local 
anodyne applications afford much relief, and may be advantageously 
used along with the poultices and stupes, either by sprinkling their sur- 
face freely with laudanum or chloroform and belladonna liniment, or 
by soaking the flannels in poppy-head fomentations. It is needless to 
say lhat the most absolute rest in bed should be enjoined, even in slight 
cases, and that the limb should be effectually guarded from undue pres- 
sure by a cradle or some similar contrivance. Local counter-irritation 
has been strongly recommended, and frequent blisters have been consid- 
ered by some to be almost specific. I should myself hesitate to use 
blisters, as they certainly would not be soothing applications, and one 
hardly sees how they can be of much service in hastening the absorption 
of the effusion. 

Constitutional Treatment. — During the acute stage of the disease the 
constitutional treatment must be regulated by the condition of the pa- 
tient. Light but nutritious diet must be administered in abundance, 
such as milk, beef-tea, and soups. Should there be much debility, stim- 
ulants in moderation may prove of service. With regard to medicines, 
we shall probably find benefit from such as are calculated to improve 
the condition of the blood and the general health of the patient. Chlo- 
rate of potash, with diluted hydrochloric acid, quinine., either alone or 
in combination with sesquicarbonate of ammonia, the tincture of the 
perchloride of iron, are the drugs that are most likely to prove of ser- 
vice. Alkalies and other medicines, which have been recommended in 



PERIPHERAL VENOUS THROMBOSIS. 643 

the hope of hastening the absorption of coagula, must be considered as 
altogether useless. Pain must be relieved and sleep procured by the 
judicious use of anodynes, such as Dover's powder, the subcutaneous 
injection of morphia, or chloral. Generally, no form answer- so well 
as the hypodermic injection of morphia. 

Subsequent Local Treatment. — When the acute symptoms have abated 
and the temperature has fallen, the poultices and stupes may be discon- 
tinued and the limb swathed in a flannel roller from the toes upward. 
The equable pressure and support thus afforded materially aid the 
absorption of the effusion and tend to diminish the size of the Limb. 
At a still later stage very gentle inunctions of weak iodine ointment 
may be used with advantage once a day before the roller is applied. 
Shampooing and friction of the limb, generally recommended for the 
purpose of hastening absorption, should be carefully avoided, on account 
of the possible risk of detaching a portion of the eoagulum and produ- 
cing embolism. This is no merely imaginary danger, as the following 
fact narrated by Trousseau proves: "A phlegmasia alba dolens had 
appeared on the left side in a young woman suffering from peri-uterine 
phlegmon. The pain having ceased, a thickened venous trunk was felt 
on the upper and internal part of the thigh. Rather strong pressure 
was being made, when M. Demarquay felt something yield under his 
fingers. A few minutes afterward the patient was attacked with dread- 
ful palpitation, tumultuous cardiac action, and extreme pallor, and death 
was believed to be imminent. After some hours, however, the oppres- 
sion ceased, and the patient eventually recovered. A slightly-attached 
eoagulum must have become separated and conveyed to the bearl or 
pulmonary artery." 1 Warm douches of water — of salt water, if it can 
be -obtained — may be advantageously used in the later stages of the dis- 
ease, and they may be applied night and morning, the limb being hand- 
aged in the interval. The occasional use of the electric current i- said 
to promote absorption, and it would seem likely to he a serviceable 
remedy. 

Change of Air, etc. — When the patient is well enough to he moved 
a change of air to the seaside will he of value. Great caution, however, 
should be recommended in using the limb, and it is far better not t<> inn 
the risk of a relapse by any undue haste in this respect. It is well t<> 
warn the patient and her friends that a considerable time must <•!' n< 
sity elapse before the local signs of the disease have completely disa] 
peared. 

1 Trousseau, "Cliniquede I'Hdtel Dieu," in Q<u <'■ H6p. } I860, p. 577. 



ce — 

)- 



644 THE PUERPERAL STATE. 



CHAPTER X. 

PELVIC CELLULITIS AND PELVIC PEEITONITIS. 

Feom the earliest time the occurrence after parturition of severe forms 
of inflammatory disease in and about the pelvis, frequently ending in sup- 
puration, has been well known. It is only of late years, however, that 
these diseases have been made the subject of accurate clinical and patho- 
logical investigation, and that their true nature has begun to be under- 
stood. Nor is our knowledge of them as yet by any means complete. 
They merit careful study on the part of the accoucheur, for they give 
rise to some of the most severe and protracted illnesses from which puer- 
peral patients suffer. They are often obscure in their origin and apt to 
be overlooked, and they not rarely leave behind them lasting mischief. 

These diseases are not limited to the puerperal state. On the contrary, 
many of the severest cases arise from causes altogether unconnected with 
childbearing. These will not be now considered, and this chapter deals 
solely with such forms as may be directly traced to childbirth. 

Two Distinct Forms. — Modern researches have demonstrated that 
there are two distinct varieties of inflammatory disease met with after 
labor, which differ materially from each other in many respects. In one 
of these the inflammation affects chiefly the connective tissue surround- 
ing the generative organs contained within the pelvis, or extends up 
from beneath the peritoneum and into the iliac fossae. In the other it 
attacks that portion of the peritoneum which covers the pelvic viscera, 
and is limited to it. 

So much is admitted by all writers, but great obscurity in description, 
and consequent difficulty in understanding satisfactorily the nature of 
these affections, have resulted from the variety of nomenclature which 
different authors have adopted. 

Thus, the former disease has been variously described as pelvic cellu- 
litis, peri-uterine phlegmon, parametritis, or pelvic abscess ; while the 
latter is not unfrequently called perimetritis, as contradistinguished from 
parametritis. The use of the prefix para or peri to distinguish the cel- 
lular or peritoneal variety of inflammation, originally suggested by Vir- 
chow, has been pretty generally adopted in Germany, and lias been 
strongly advocated in this country by Matthews Duncan. It has never, 
however, found much favor with English writers, and the similarity of 
the two names is so great as to lead to confusion. I have therefore 
selected the terms " pelvic peritonitis" and "pelvic cellulitis" as convey- 
ing in themselves a fairly accurate notion of the tissues mainly involved. 

Importance of Distinguishing the Two Classes of Cases. — The import- 
ant fact to remember is that there exist two distinct varieties of inflam- 
matory disease, presenting many similarities in their course, symptoms, 
and results, often occurring simultaneously, but in the main distinct in 
their pathology and capable of being differentiated. Thomas compares 



PELVIC CELLULITIS AXD PELVIC PERITOXITIS. 645 

them — and, as serving to fix the facts on the memory, the illustration is 
a good one — to pleurisy and pneumonia. "Like them," he savs, " thev 
are separate and distinct, like them affect different. kinds of structure, 
and like them they generally complicate each other." It might there- 
fore be advisable, as most writers on the disease; occurring in the non- 
puerperal state have done, to treat of them in two separate chapters. 
There is, however, more difficulty in distinguishing them as puerperal 
than as non-puerperal affections, for which reason, as well as for the sake 
of brevity, I think it better to consider them together, pointing out as 
I proceed the distinctive peculiarities of each. 

Seat of Disease. — When attention was first directed to this class of 
diseases the pelvic cellular tissue was believed to be the only structure 
affected. This was the view maintained by Xonat, Simpson, and many 
modern writers. Attention was first prominently directed to the import- 
ance of localized inflammation of the peritoneum, and to the fact that 
many of the supposed cases of cellulitis were really peritonitic, by Ber- 
nutz. There can be no doubt that he here made an enormous step in 
advance. Like many authors, however, he rode his hobby a little too 
hard, and he erred in denying the occurrence of cellulitis in many cases 
in which it undoubtedly exists. 

Etiology. — The great influence of childbirth in producing these dis- 
eases has long been fully recognized. Courty estimates that about t\v»>- 
thirds of all the cases met with occur in connection with delivery or 
abortion, and Duncan found that, out of 40 carefully-observed cases, 25 
were associated with the puerperal state. 

The Inflammation is Secondary, and never Idiopathic. — It i- pretty gen- 
erally admitted by most modern writers that both varieties of the dis- 
ease are produced by the extension of inflammation from either the ute- 
rus, the Fallopian tubes, or the ovaries. This point has been especially 
insisted on by Duncan, who maintains that the disease is never idiopathic, 
and is " invariably secondary either to mechanical injury, or to the ex- 
tension of inflammation of some of the pelvic viscera, or to the irrita- 
tion of the noxious discharges through or from the tube- or ovaries." 

Often Intimately connected with Septicaemia. — Their intimate connec- 
tion with puerperal septicaemia is also a prominenl tact in the natural 
history of the diseases. Barker mentions a curious observation illus- 
trative of tin-, that when puerperal fever is endemic in the Bellevue 
Hospital in New York cases of pelvic peritonitis and cellulitis are also 
invariably met with. Olshausen has also remarked that in tli«' Ly- 
ing-in Hospital at Halle during the autumn vacation, when the pa- 
tients are not attended by practitioners, and when, therefore, the 
chance of septic infection being conveyed t<> them is less, these inflam- 
mations are almost always absent. A- inflammation of the lining mem- 
brane of the uterus, of the vaginal mucous membrane, and of the pelvic 
connective tissue are of very constant occurrence a- local phenomena oi 
septic absorption, the connection between the two classes "i cases a 
readily susceptible of explanation. Schroeder, indeed, rther, 

and includes bis description of these diseases under tli<> head of puer- 
peral fever. They do not, however, necessarily depend upon it ; for f 
although it must be admitted that cases "I' this kind I'^nw a large pro* 



646 THE PUERPERAL STATE. 

portion of those met with, others unquestionably occur which cannot be 
traced to such sources, but are the direct result of causes altogether un- 
connected with the inflammation attending on septic absorption, such as 
undue exertion shortly after delivery or premature coition. Mechanical 
causes may beyond doubt excite the disease in a woman predisposed by 
the puerperal process, but they cannot fairly be included under the head 
of puerperal fever. 

Seat of the Inflammation in Pelvic Cellulitis. — Abundance of areolar 
tissue exists in connection with the pelvic viscera which may be the seat 
of cellulitis. It forms a loose padding between the organs contained in 
the pelvis proper, surrounds the vagina, the rectum, and the bladder, and 
is found in considerable quantity between the folds of the broad ligaments. 
From these parts it extends upward to the iliac fossae and the inner sur- 
face of the abdominal parietes. In any of these positions it may be the 
seat of the kind of inflammation we are discussing. The essential cha- 
racter of the inflammation is similar to that which accompanies areolar 
inflammation in other parts of the body. There is first an acute inflam- 
matory oedema, followed by the infiltration of the areolae of the connec- 
tive tissue with exudation, and the consequent formation of appreciable 
swellings. These may form in any part of the pelvis. Thus, we may 
meet with them — and this is a very common situation — between the 
folds of the broad ligaments, forming distinct hard tumors connected 
with the uterus and extending to the pelvic walls, their rounded outlines 
being readily made out by bi-manual examination. If the cellulitis be 
limited in extent, such a swelling may exist on one side of the uterus 
only, forming a rounded mass of varying size and apparently attached to 
it. At other times the exudation is more extensive, and may completely 
or partially surround the uterus, extending to the cellular tissue between 
the vagina and rectum or between the uterus and the bladder. In such 
cases the uterus is imbedded and firmly fixed in dense, hard exudation. 
At other times the inflammation chiefly affects the cellular tissue cover- 
ing the muscles lining the iliac fossa?. There it forms a mass, easily 
made out by palpation, but on vaginal examination little or no trace of 
the exudation can be felt, or only a sense of thickness at the roof of the 
vagina on the same side as the swelling. 

Seat, of the Inflammation in Pelvic Peritonitis. — In pelvic peritonitis 
the inflammation is limited to that portion of the peritoneum which 
invests the pelvic viscera. Its extent necessarily varies with the intens- 
ity and duration of the attack. In some cases there may be little more 
than irritation, while more often it runs on to exudation of plastic mate- 
rial. The result is generally complete fixation of the uterus and hard- 
ening and swelling in the roof of the vagina, and the lymph poured out 
may mat together the surrounding viscera, so as to form swellings diffi- 
cult, in some cases, to differentiate from those resulting from cellulitis. 
On post-mortem examination the pelvic viscera are found extensively 
adherent, and the agglutination may involve the coils of the intestine in 
the vicinity, so as sometimes to form tumors of considerable size. 

Relative Frequency of the Two Forms of Disease. — The relative fre- 
quency of these two forms of inflammation as puerperal affections is not 
easy to ascertain. In the non-puerperal state the peritonitic variety is 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 647 

much the more common, but in the puerperal state they very generally 
complicate each other, and it is rare for cellulitis to exist to any great 
extent without more or less peritonitis. 

Symptomatology. — The earliest symptom is pain in the lower pan >f 
the abdomen, which is generally preceded by rigor or chilliness. The 
amount of pain varies much. Sometime- ir is comparatively Blight, and 
it is by no means rare to meet with patients, the subjects of very consid- 
erable exudations, who suffer little more than a certain sense of weight 
and discomfort at the lower part of the abdomen. On the other hand, 
the suffering may be excessive, and is characterized by paroxysmal 
exacerbations, the patient being comparatively free from pain for several 
successive hours, and then having attacks of the most acute agony. 
Schroeder says that pain is always a symptom of peritonitis, and that it 
does not exist in uncomplicated cellulitis. The swellings of cellulitis 
are certainly sometimes remarkably free from tenderness, and I have 
often seen masses of exudation in the iliac fossae which could bear even 
rough handling. On the other hand, although this i- certainly more 
often met with in non-puerperal cases, the tenderness over the abdomen 
is sometimes excessive, the patient shrinking from the slightest touch. 
The pulse is raised, generally from 100 to 120, and the thermometer 
shows the presence of pyrexia. During the entire course of the disease 
both these symptoms continue. The temperature is often very high, but 
more frequently it varies from 100° to 104°, and it generally shows 
more or less marked remissions. In some cases the temperature i- said 
not to be elevated at all, or even to be subnormal, but this is certainly 
quite exceptional. Other signs of local and general irritation often 
exist. Among them — and most distinctly in cases of peritonitis — are 
nausea and vomiting and an anxious, pinched expression of the counte- 
nance, while the local mischief often causes distressing dysuria and 
tenesmus. The latter is especially apt to occur when there is exudation 
between the rectum and vagina, which presses on the bowel ( The pa- 
sage of feces, unless in a very liquid form, may then cause intolerable 
suffering. 

The Symptoms often Insidious in their Onset. — Such symptoms may 
show themselves within a few day- after delivery, and then they can 
barely fail to attract attention. On the other hand, they maj not com- 
mence for some weeks after labor, and then they are often Insidious in 
their onset and apt to be overlooked. It i- far from rare to meet with 
cases six weeks or more after confinement in which the patient complains 
of little beyond a feeling of malaise and discomfort, and in which, on 
investigation, <i considerable amount of exudation Is detected which 
had previously entirely escaped observation. 

Results of Physical Examination. — On introducing the finger into the 
vagina it will be found to be hot and swollen, in some cases distinctly 
edematous, and on peaching the vaginal cul-de-sat the existence "i exu- 
dation may generally be made out. The amount of this varies much. 
Sometimes, especially in the early stage of the disease, there Is little more 
than a diffuse sense of thickness and Induration at either side 
behind, the uterus. More generally, careful bi-manual examination 
enables us to detect ft distinct hardening and swelling, possiblj a inn...!- 



648 THE PUERPERAL STATE. 

of considerable size, which may apparently be attached to the sides of 
the uterus and rise above the pelvic brim, or may extend quite to the 
pelvic walls. The examination should be very carefully and systemat- 
ically conducted with both hands, so as to explore the whole contour of 
the uterus before, behind, and on either side, as well as the iliac fossae, 
otherwise a considerable exudation might readily escape detection. When 
the exudation is at all great more or less fixity of the uterus is sure to 
exist, and is a very characteristic symptom. The womb, instead of being 
freely movable by the examining finger, is firmly fixed by the surround- 
ing exudation, and in severe forms of the disease is quite encased in it. 
More or less displacement of the organ is also of common occurrence. 
If the swelling be limited to one side of the pelvis or to Douglas's space, 
the uterus is displaced in the opposite direction, so that it is no longer 
in its usual central position. 

The Two Forms cannot Always be Distinguished. — The differential 
diagnosis of pelvic cellulitis and pelvic peritonitis cannot always be 
made, and indeed in many cases it is impossible, since both varieties of 
disease coexist. The elements of differentiation generally insisted on 
are the greater general disturbance, nausea, etc. in pelvic peritonitis, 
with an earlier commencement of the symptoms after labor. The swellings 
of pelvic peritonitis are also more tender, with less clearly-defined out- 
line than those of cellulitis. When the cellulitis involves the iliac fossa, 
the diagnosis is of course easy, and then a continuous retraction of the 
thigh on the affected side (an involuntary position assumed with the view 
of keeping the muscles lining the iliac fossa at rest) is often observed. 
When the inflammation is chiefly limited to the cavity of the pelvis, the 
distinction between the two classes of cases cannot be made with any 
degree of certainty. 

Terminations. — Both forms of disease may end either in resolution or 
in suppuration. In the former case, after the acute symptoms have 
existed for a variable time — it may be for a few days only, it may be 
for many weeks — their severity abates, the swellings become less tender 
and commence to contract, become harder, and are gradually absorbed, 
until at last the fixity of the uterus disappears, and it again resumes its 
central position in the pelvic cavity. This process is often very gradual. 
It is by no means rare to find a patient, even some months after the 
attack, when all acute symptoms have long disappeared, who is even 
able to move about without inconvenience, in whom the uterus is still 
immovably fixed in a mass of deposit or is at least adherent in some 
part of its contour. More or less permanent adhesions are of common 
occurrence, and give rise to symptoms of considerable obscurity, which 
are often not traced to their proper source. 

Symptoms of Suppuration. — When the inflammation is about to ter- 
minate in suppuration, the pyrexial symptoms continue, and eventually 
well-marked hectic is developed, the temperature generally showing a 
distinct exacerbation at night. At the same time, rigors, loss of appetite, 
a peculiar yellowish discoloration of the face, and other signs of suppu- 
ration show themselves. The relative frequency of this termination is 
variously estimated by authors. Duncan quotes Simpson as calculating 
it as occurring in half the cases of pelvic cellulitis, but states his oayii 



PELVIC CELLULITIS AXD PELVIC PERITONITIS. 649 

belief that it is much more frequent. West observed it in 23 oui of 43 

cases following delivery or abortion, and McCHntock in 'M out of 7". 
Schroeder says that he has only once seen suppuration in 92 cases of dis- 
tinctly demonstrable exudation — a result which is certainly totally opposed 
to common experience. Barker also states that in hi- experience suppu- 
ration in either pelvic peritonitis or cellulitis " is very rare, except when 
they are associated with pyaemia or puerperal fever." It i- certain that 
suppuration is more likely to occur in pelvic cellulitis than in pelvic 
peritonitis, but it unquestionably occurs, in this country at least, much 
more frequently than the statements of either of these authors would 
lead us to suppose. 

Channels through which Pus may Escape. — The pus may find an exit 
through various channels. In pelvic cellulitis, more especially when the 
areolar tissue of the iliac fossa is implicated, the most common site <•!' 
exit is through the abdominal wall. It may, however, open at other 
positions, and the pus may find its way through the cellular tissue ami 
point at the side of the anus or in the vagina, or it may take even a more 
tortuous course and reach the inner surface of the thigh. Pelvic ab- 
scesses not uncommonly open into the rectum or bladder, causing very 
considerable distress from tenesmus or dysuria. According t<> I [ervieux, 
it is chiefly the peritoneal varieties which open in. this way. Nut unire- 
quently more than one opening is formed, and when the pus has bur- 
rowed for any distance long fistulous tracts result, which secrete pus 
for a length of time and are very slow to heal. Rupture of an abscess 
into the peritoneal cavity, especially of a peritonitic abscess, i- a j >. » — i I »lt- 
(but fortunately a very rare) termination, and will generally prove fatal 
by producing general peritonitis. In one case, which 1 have recorded in 
the fifteenth volume of the Obstetric"/ Transactions, suppuration was 
followed by extensive necrosis of the pelvic bones.- Two similar cases 
are related by Trousseau in his Clinical Medicine, but I have doI been 
able to meet with any other examples of this rare complication, which 
was probably rather the result of some obscure septicaemic condition 
than of extension of the inflammation. 

Prognosis. — The prognosis is favorable a-- regards ultimate recovery, 
but there is great risk of a protracted illness \\hi<-h may Beriously impair 
the health of the patient, especially if suppuration result Hence h is 
necessary to be guarded in an expression of opinion a- i<> the conse- 
quences of the disease. Secondary mischief i- alSO far from tinlik. I\ !-. 

follow from the physical changes produced by the exudation, such as 
permanent adhesion- or malpositions of the uterus or organic alterations 
in the ovaries or Fallopian tubes. 

Treatment. — In the treatmenl of both forms of disease the important 
points to bear in mind are the relief of pain and the necessity or abso- 
lute rest; and to these objects all our measures must !"■ subordinate, 
since it is quite hopeless to attempt t<> cut short the in fl a mm ation by 
any active medication. 

If the disease he recognized .-it a very early stage, the local abstraction 
of blood, by the application of ;i few leeches i" the groi ' I i the hem- 
orrhoidal veins, may give relief; bul the influence of this remedy has 
been greatly exaggerated, and when the disease is of any standing n i- 



650 THE PUERPERAL STATE. 

quite useless. Leeches to the uterus, often recommended, are, I believe, 
likely to do more harm than good (unless in very skilful hands), from 
the irritation produced by passing the speculum. Opiates in large doses 
may be said to be our sheet-anchor in treatment whenever the pain is at 
all severe, either by the mouth, in the form of morphia suppositories, or 
injected subcutaneously. In the not uncommon cases in which pain 
comes on severely in paroxysms the opiates should be administered in 
sufficient quantity to lull the pain ; and it is a good plan to give the 
nurse a supply of morphia suppositories (which often act better than any 
other form of administering the drug), with directions to use them 
immediately the pain . threatens to come on. When there is much 
pyrexia large doses of quinine may be given with great advantage along 
with the opiates. The state of the bowels requires careful attention. 
The opiates are apt to produce constipation, and the passage of hardened 
feces causes much suffering. Hence it is desirable to keep the bowels 
freely open. Nothing answers this purpose so well as small doses of 
castor oil, such as half a teaspoonful given every morning. Warmth 
and moisture, constantly applied to the lower part of the abdomen, 
either in the form of large poultices of linseed meal, or, if these prove 
too heavy, of spongio-piline soaked in boiling water, give great relief. 
The poultices may be advantageously sprinkled with laudanum or bel- 
ladonna liniment. I say nothing of the use of mercurials, iodide of 
potassium, and other so-called absorbent remedies, since I believe them 
to be quite valueless and apt to divert attention from more useful plans 
of treatment. 

Importance of Rest, — The most absolute rest in the recumbent posi- 
tion is essential, and it should be persevered in for some time after the 
intensity of the symptoms is lessened. The beneficial effect of rest in 
alleviating pain is pften seen in neglected cases the nature of which has 
been overlooked, instant relief following the laying up of the patient. • 

Counter-irritation. — When the acute symptoms have lessened, absorp- 
tion of the exudation may be favored and considerable relief obtained 
from counter-irritation, which should be gentle and long continued. 
The daily use of tincture of iodine until the skin peels perhaps best 
meets this indication, but frequently-repeated blisters are often very ser- 
viceable. This I believe to be a better plan than keeping up an open 
sore with savine ointment or similar irritating applications. 

Opening of Pelvic Abscesses. — When suppuration is established the 
question of opening the abscess arises. When this points in the groin 
and the matter is superficial, a free incision may be made ; and here, as 
in mammary abscess, the antiseptic treatment is likely to prove very ser- 
viceable. The abscess should, however, not be opened too soon, and it 
is better to wait until the pus is near the surface. The importance of 
not being in too great a hurry to open pelvic abscesses has been insisted 
on by West, Duncan, and other writers, and I have no doubt the rule 
is a good one. It is more especially applicable when the abscess is 
pointing in the vagina or rectum, where exploratory incisions are apt 
to be dangerous, and when the presence of pus should be positively 
ascertained before operating. We have in the aspirator a most useful 
instrument in the treatment of such cases, which enables us to remove 



PELVIC CELLULITIS AND PELVIC PERITONITIS. 651 

• 
the greater part of the pus without any risk, and the use of which is not 
attended with danger even if employed prematurely, [f it do no* suffi- 
ciently evacuate the abscess, a free opening can afterward be safely made 
with the bistoury. The surgical treatment of pelvic abscess is, however, 
too w r ide a subject to admit of being satisfactorily treated here. 

Diet and Regimen. — The diet should be abundant, but simple and 
nutritious. In the early stages of the disease milk, beef-tea, eggs, and 
the like will be sufficient. After suppuration a large quantity of ani- 
mal food is necessary, and a sufficient amount of stimulants. The drain 
on the system is then often very great, and the amount of nourishment 
patients will require and assimilate when a copious purulent discharge is 
going on is often quite remarkable. A general tonic plan of medication 
is also indicated, and such drugs as iron, quinine, and cod-liver oil will 
prove useful. 



INDEX. 



ABDOMEN, adipose enlargement of, 157 
enlargement of, as a sign of preg- 
nancy, 149 
state of, after delivery, 551 
Abdominal pregnancy. See Extra-uterine 

Pregnancy. 
Abortion, 242 

causes of, 244 

difficulty in procuring artificial, 248 
liability to recurrence of, 243 
production of, in vomiting of preg- 
nancy, 201 
retention of secundines in, 249, 253 
symptoms of, 248 
treatment of, 249 

value of opium in prevention of, 249 
[250] 
Abscess of mammae. See Mammary Ab- 

86688. 

Abscess, pelvic. See Pelvic Cellulitis. 
After-pains, 552 

treatment of, 554 
Age, influence of, in labor, 340 
Albuminuria in pregnancy, 206 

relation of, to eclampsia, 576 

relation of, to puerperal insanity, 586 
Allantois, 167 
Amnii, liquor, 109 
Amnion, formation of, 106 

pathology of, 236 

structure of, 109 
Amputations (infra-uterine), 240 
Anaemia in pregnancy, 206 
Anaesthesia in labor, 295 

in forceps operations, 478 

value of, in difficult cases of turning, 
470 
Anasarca in pregnancy, 209 
Anteversion of the gravid uterus, 217 
Antiseptic midwifery, 604 
Apoplexy during or after labor, 635 
Arbor rite, 59 
Area germinativa, 105 
Area pellucida, 105 
Areola, 80 

changes of, during pregnancy, 1 l'i 
Arm, presentation of. See Shoulder Pre- 
senlation. 

dorsal displacement of, 330 
Arterial transfusion, 542 
Artificial human milk, 571 
Artificial respiration in cases of apparent 
still-birth, 558 



Ascites as a cause of dystocia, 373 
Asphyxia (idiopathic), 635 

of new-born children. 557 
Atropine, hypodermic injection of. in ri- 
gidity of cervix, 352 
Auscultatory signs of pregnancy. 152 



BAGS (Barnes's). See Dilators. 
Ballottement, 151 
Basilyst. the, 508 
Bi-lobed uterus, gestation in, 192 
Binder, uses of, 294 

[application of, 290] 
Bladder, distension of. as a cause of pro- 
tracted labor, 340 

exfoliation of lining membrane of, 213 

state of, after delivery, 553 
Blastodermic membrane, 99 

division and layers of 105 
Blood, alteration in, alter delivery, 547 

changes of, during; pregnancy, 139 
Blood-diseases transmitted to foetus, 23? 
Blunt-hook in breech presentatL i 

Bowels, action of. after delivery. 

Breech presentations. See /' /' 

tut ions. 
Broad ligaments of uterus, 68 
Bronchitis as a cause of protracted labor, 

340 
Brow presentations, 31S 



C.i:saim:a\ srcti<,n. :; 3 511. 

513 

[in America. 526] 

[in Greal Britain, 525] 

causes of mortality after, 517 

causes requiring the operation, 

description <>f. 521 

history o£ 51 1 

[ unproved methods of perform in 

[mortality in cases of fibroid tumor, 

3571 
( in pelvic exostosis, 
ost-mortem operation 

irocess of < bnnsb 

[of Frank, 522] 

[of Kehrer 

oger, •">•_' I ] 
results t<> child it 
[results in Greal Britaii 

I fnited Stab - 1 ompared, 

(553 



c 



654 



INDEX. 



Cesarean section — 

statistics of, 513 

[latest American, 513] 

[in American dwarfs, 514] 

substitutes for, 526 

sutures in, 522 

[sutures in the United States, 522] 

[in transverse position of foetus, 330] 
Calculus of bladder obstructing labor, 359 
Caput succedaneum, 279 
Carcinoma in pregnancy, 223 

obstructing labor, 353 
Cardiac murmurs in pulmonary obstruc- 
tion, 629 
Caries of teeth in pregnancy, 204 
[Carolina twins, birth of, 370] 
Carunculse myrtiformes, 52 
Catheter, introduction of, 51 
Caul, 264 

Cellulitis, pelvic. See Pelvic Cellulitis. 
Cephalotribe, 500 
Cephalotripsy. See Craniotomy. 
Cervix uteri, 58 

alterations of, after childbirth, 58 

cavity of, 59 

dilatation of, in labor, 259 

hypertrophic elongation of, 353 

impaction of, before foetal head, 286 

incision of, for rigidity, 354 

lacerations of, 439 

modification of, by pregnancy, 136 

mucous membrane of, 63 

organic causes of rigidity of, 353 

rigidity of, as a cause of protracted 
labor, 351 

treatment of rigidity, 352 

villi of, 64 
Charlotte, Princess of Wales, death of, 348 
Child (the new-born). See Infant. 
Child, risks to, in forceps operations, 486 
Childbirth, mortality of, 546 
Chloral in labor, 295 

in rigidity of cervix, 352 
Chloroform in labor, 296 

[deaths from, 297] 

in difficult cases of turning, 462 

in rigidity of cervix, 352 
Chorea in pregnancy, 212 
Chorion, 110 

vesicular degeneration of, 229 
Circulation of foetus, 129 
Cleavage of yelk, 99 
Clitoris, 48 
Coccyx, 35 

ligaments of, 36 

ossification of, 36 

mobility of, 36 
Cold in the treatment of puerperal hyper- 
pyrexia, 619 
Colostrum, 559 
Complex presentations, 330 
Conception, signs of, 143 
Constipation in pregnancy, 202 
Constriction of uterus, tetanoid, 355 
Continued fever in pregnancy, 221 



Convulsions puerperal. See Eclampsia. 
Corps reticule, 108 
Corpus luteum, 84 

false, 85 
Cranioclast, 500 
Craniotomy, 497 

cases requiring, 502 

comparative merits of, and cephalo- 
tripsy, 505 

description of cephalotripsy, 506 

extraction of head by craniotomy for- 
ceps, 508 

method of perforating, 504 

perforators, 499 

perforation of after-coming head, 505 

religious objections to, 498 
Craniotomy forceps, 500 
Crotchets, 499 

Cyclical theory of menstruation, 92 
Cystocele, obstructing labor, 359 



DEATH, apparent, of new-born child. 
See Infant. 

sudden, during labor and the puer- 
peral state, 635 

from air in the veins, 636 

functional causes of, 635 

organic causes of, 635 
Decapitation of foetus, 510 
Decidua, 100 

at end of pregnancy and after deliv- 
ery, 104 

cavity between d. vera and reflex a, 
104 

divisions of, 100 

fatty degeneration of, as the cause of 
labor, 256 

formation of d. reflexa, 102 

structure of, 101 
Delivery, state of patient after, 547 

contraction of uterus after, 549 

management of patient after, 553 

nervous shock after, 547 

prediction of date of, 161 

signs of recent, 164 

state of pulse after, 547 

weight of uterus after, 550 
Diabetes, 143 
Diameters of foetal skull, 127 

of pelvis, 41 
Diarrhoea in pregnancy, 202 
[Diet, milk, in nursing mothers, 5(54] 
Diet of lying-in women, 554 
Dilators (caoutchouc) in the induction of 
premature labor, 453 

in rigidity of cervix, 353 
Diphtheria in the puerperal state, 600 
Diseases of pregnancy, 198 

albuminuria, 206 

anaemia and chlorosis, 206 

carcinoma, 223 

cardiac diseases, 222 

chorea, 212 

constipation, 202 



IXDEX. 






Diseases of pregnancy — 

diarrhoea, 202 

disorders of the nervous system, 211 
respiratory organs, 2(J4 
teeth, 204' 
urinary system, 213 

displacements of the gravid uterus, 216 

epilepsy, 223 

eruptive fevers, 221 

fibroid tumors, 225 

haemorrhoids, 203 

icterus, 223 

leucorrhcea, 214 

ovarian tumor, 224 

palpitation, 205 

paralysis, 211 

pneumonia, 221 

pruritus, 215 

ptyalism, 204 

syncope, 205 

syphilis, 222 

varicose veins, 215 

vomiting (excessive), 198 
Dropsies affecting the foetus, 239 
Ductus arteriosus, 129 

venosus, 129 
Dvstocia from foetus, 363 



ECLAMPSIA, 573 
cause of death in, 576 
condition of patient between the at- 
tacks, 575 
confusion from defective nomencla- 
ture, 573 
exciting causes of, 578 
obstetric management in, 581 
pathology of, 576 
premonitory symptoms of, 574 
relation of, to labor, 575 
results io mother and child in, 576 
symptoms of, 574 
transfusion in, 536 

Traiibe and Kosenstein's theory of, 577 
treatment of, 579 
uraemic theory of, 576 
venesection in. 579 
views of MacDonald, 578 
Ecraseur, use of, as a substitute lor cranio- 
tomy. 501 
Embolism. See Thrombosis. 
Embryotomy, 509 
Emotion, mental, as a cause of protracted 

labor. 340 

Epiblast, 105 

Epilepsy, in pregnancy, 223 
Epileptic convulsions, 574 
Ergot of rye, 342 

as a means of inducing Labor, 152 

objections to use of, 3 13 
mode of administration, .".12 
value of, after delivery, 29 1 

Ergotin. hypodermic injection of, in i«»i- 
partum hemorrhage, 122 

Eruptive fevers in pregnancy, 221 



Erysipelas as a cause of puerperal sep- 
ticaemia. 599 

Ether in labor, 297 [298] 

Evisceration, 511 

Exhaustion, Importance of distinguishing 
between temporary and permanent 
in labor, .'J42 

Expression, uterine see V of the 

placenta. 291 

Extra-uterine pregnancy, 171 
abdominal variety of, 182 
causes of, 17:; 

changes of the lotus in. 185 
classification of. 172 
diagnosis of abdominal variety, 186 
diagnosis of tubal variety, 177 
[faradie current in, 180] 
gastrotomy in. 182, 187 
[non-removal of placenta in. 1 ! 
[laparotomy, primary and secondary, 

relative ri>ks of. 1 89 | 
pseudo-labor in. 1 8 ■! 
vaginal section in, 179 
[Mathieson's case of. 179] 
symptoms of rupture in. 17o' 
treatment alter rupture, l s 2 
[Lawson Tait's operations, 182 
treatment of abdominal variety, l v 6 
tubal variety, 175 

treatment of tubal variety. 178 



FA.CE presentation, 310 
causes of, 310 

diagnosis of. 311 

difficulties connected with, •"-17 

erroneous views formerly entertained 

of, 310 
mechanism of deliver) in. 312 
mento-posterior positions in. 314 
prognosis in, 316 

treatment of, 31 6 

Fallopian tubes, 71 

False corpus Luteum, s ~> 

False pains, character and treatment <<(. 

282, 283 
Faradization in apparent stillbirth 

in destroying the vitality of the foetus 

in abnormal pregnancies, 1 30 
in hemorrhage after delivery, 

in labor, '■'• 1 I 

Fibroid tumor, in pregnane) 
obsl i"u< ting labor, 356 [ '■> >7 ] 

Fillet, 

in breech presentations, 
nature of t Im- instrument, 196 
objections to il 

Flattened peh is, 

Foetal head, anatomy "f. 120 

induction of premature labor, lor 

lai 

inda of, in i 
Foetus, anatomy and physiology of, 118 
[anencephaloua, producinj 

-iii 



656 



INDEX. 



Foetus- 
appearance of a putrid, 241 

appearance of, at various stages of de- 
velopment, 118 

at term, 119 

circulation of, 129 

changes in circulation of, as cause 
of labor, 255 

changes in position of, during preg- 
nancy, 123 

[cleansing without water, 559] 

death of, 241 

detection of position in utero by pal- 
pation, 124 

early viability of, 243 

excessive development of, as a cause 
of difficult labor, 374 

explanation of its position in utero, 
125 

functions of, 127 

nutrition of, 127 

pathology of, 237 

position of, in utero, 123 

respiration of, 128 

signs and diagnosis of death of, 242 
Fontanelles, 120 
Foot, diagnosis of, 301 
Foot presentations. See Pelvic Presentations. 
Foramen ovale, 129 
Forceps, 472 

action of, 476 

advantages of pelvic curve in, 473 

application of, to after-coming head 
in breech presentations, 307 

application of, within the cervix, 355 

[carried over abdomen to complete 
delivery of head, 494] 

[at inferior strait, 491] 

[at superior strait, 493] 

cases in which a straight instrument 
should be used, 473 

dangers of, 347, 485 

dangers of, to child, 486 

description of, 472 

description of the operation, 479 

difference between high and low ope- 
rations, 478 

disadvantages of a weak instrument, 
476 

frequent use of, in modern practice, 
346, 472 

high operations, 484 
[in America, 486] 

long, 474 

preliminary considerations before us- 
ing, 478 

short, 472 

use of anaesthetics in forceps deliverv, 
479 

use of, in deformed pelvis, 395 

use of, in difficult occipi to-posterior 
positions, 320 

use of, in protracted labor, 346 

[Bedford's, 489] 

[Davis's, 488] 



Forceps — 

[Elliot's, 490] 

[Hodge's, 488] 

[Meigs's craniotomy, 509] 

[Sawver s, 490] 

[Wallace's, 488] 

[White's, 490] 
Forceps saw, 501 
Fossa navicularis, 53 
Funis. See Umbilical Cord. 
Funnel-shaped pelvis, 378 



pALACTAGOGUES, 564 

\ J Galactorrhea, 565 

Galvanism as a means of inducing labor, 

452 
Gangrene of limbs from arterial obstruc- 
tion, 634 
Gastrotomy, after rupture of uterus, 438 

in extra-uterine pregnancy, 182, 187 
Gastro-elytrotomy. See Laparo-elytro- 

tomy. 
[Gastro-hysterotomy, possibilities of, 528] 
Generative organs, in the female, 48 

division according to function, 48 
Germinal vesicle, disappearance of, after 

impregnation, 98 
Gestation. See Pregnancy. 
Glycosuria in pregnancy, 143 

in lactation, 549 
Graafian follicle, 75 

structure of, 77 



HEMATOCELE, obstructing labor, 360 
[Hand, introduction of in occipito-pos- 
terior positions, 322] 
Hand-feeding of infants, 569 
ass's milk in, 569 
artificial human milk in, 570 
causes of mortality in, 569 
cow's milk in, and its preparation, 

570 
goat's milk in, 570 
method of, 572 
Head presentations, 268 

description of cranial positions in, 

268, 269 
division of, 269 
frequency of first position, 268 
explanation of, 270 
mechanism of first position, 272 
second position, 276 
third position, 276 
fourth position, 278 
relative frequency of various posi- 
tions, 269 
Heart, diseases of, in pregnancy, 222 

hypertrophy of, in pregnancy, 141 
Hemorrhage, accidental, 411 

causes and pathology of, 412 
concealed internal, 413 
diagnosis, prognosis, and treatment of 
concealed internal, 413, 414 



INDEX. 



657 



Hemorrhage — 

prognosis of, 414 

symptoms and diagnosis of, 412 

treatment of, 414 

after delivery, 415 

causes of, 416 

constitutional predisposition to, 419 

curative treatment of, 421 

from laceration of maternal structures, 
427 

nature's mode of preventing, 266, 
415 

preventive treatment of, 420 

secondary causes of, 417 

secondary treatment of, 427 

symptoms of, 420 

transfusion of blood in, 42S 
after delivery (secondary), 428 

distinction between, and profuse lo- 
chial discharge, 428 

local causes of, 429 

treatment of, 430 
unavoidable. See Placenta Prcevia. 
Hemorrhoids, in pregnancy, 203 
Hernia, in labor, 3(30 
Hour-glass contraction of uterus, 417 [418] 

ante-partum, 855 
Hydatids of uterus. 229 
Ilydramnios, 236 

Hydrocephalus of foetus, as a cause of dif- 
ficult labor, 371 
Hydrorrhoea gravidarum, 228 
Hymen. 52 
Hypoblast, 105 
Hysteria during labor. 574 



INDUCTION of premature labor. See 
Premature Labor. 
Inertia of the uterus, frequent child-bear- 
ing as a cause of, 339 
Infant, apparent deatli of, 557 

appearance of, in cases of apparent 

death, 557 
clothing of, 559 
evils of over-suckling, 560 
management of, 561 
management of, when food disagrees, 

573 
treatment ofappareul death of, 557 
various kinds of food of, 572 
washing and dressing of, 558 
Infantile mortality, diminution of, as B 
reason for more frequent use of for- 
ceps, 3 17 
Inflammatory diseases affecting the lotus, 

239 
Injections, uterine, of hot water. 124 
Insanity i puerperal . 582 
classification of, 583 
of lactation, 588 
of pregnancy, 583 
predisposing causes ofj 583 
puerperal l proper |, 585 
causes of. 585 
42 



Insanity — 

form of, prognosis oi\ 584 
post-mortem signs of, 588 

symptoms of, 588 

transient mania during delivery. 58 1 

treatment of, 590 

treatment during convalescence, 592 

question of removal to an asylum. 592 
Insomnia in pregnancy, 211 
Intermittent fever affecting the foetus, 2 3 
Intestines, disorders of. as influencing 

labor, 340 
Inversion of uterus. See Uterus. 
Irregular uterine contractions after labor. 
417 

as a cause of lingering labor, 341 
Irritable bladder in pregnancy, 213 
Ischium, planes of the, 46 



"AUNDICE in pregnancy. 223 



KIESTEIN, 142 [143] 
Knee presentation. 301 
Knots of t he umbilical cord. 235 
Kyphotic deformity of pelvis, 386 



LABIA majora. 49 
Labia minora, 50 
Labor, 255 

age, influence of. on, 340 
anaesthesia in, 295 
arrest of, 164 
causes of. 255 

causes of precipitate, 350 
causes of protracted, 337 
character and source of pain in, 261 
character of fal.-e pains. 263 
dilatation of cervix in. 257 
duration of, 266 

effect of uterine contractions in, 267 
evil effects of protracted, 337 

induction of. Bee / ' r< '"" I 

influence of Btageof, in protracted, 337 

management of, in delbrmed peh is, 
394 

management of natural, 

management of third sta 

mechanism of, in head presentation, 
268 

[ missed, causes of, L96 ] 

obstructed by faulty condition of tbc 
soft parts, 361 

period of day at \\ hich labor com- 
mences, 267 

phenomena of, 256 

positi f patient during 

| premature, induction <•!. 166 ] 

preparatory treatment, 280 

pre< ipitab 

prolonged and precipitate 

rupture of membranes in 



658 



INDEX. 



Labor — 

symptoms of protracted, 338 

treatment of protracted, 341 
Lactation, defective secretion of milk in, 
564 

diet of nursing women during, 562 

diseases of the eye during, 566 

evil results of prolonged, 560 

excessive flow of milk in, 565 

importance of, to mother, 560 

importance of wet-nursing to child, 
560, 561 

insanity of, 588 

management of, 561 

means of arresting secretion of milk 
in, 563 

period of weaning in, 563 
Laminae dorsales, 105 
Laparo-elytrotomy, 529 

[latest statistics of, 530] 
[Laparotomies, American puerperal, 438] 
Lead-poisoning, affecting the foetus, 238 

as a cause of abortion, 247 
Leucorrhoea, in pregnancy, 214 
Lever. See Veclis. 
Liquor amnii, 109 

uses of, 110 

source of, 109 

deficiency of, 237 
Lithopsedion, 185 

Liver, acute yellow atrophy of, 223 
Lochia, 551 

variation in amount and duration of, 
552 

occasional fetor of, 552 
Lying-in hospitals, mortality in, 594 
Lypothsemia, 146, 205 



MALARIAL puerperal fever, 615 
Malpresentations, peculiar form of 
bag of membranes in, 301 
Mammary abscess, 566 

antiseptic treatment of, 567 
signs and symptoms of, 566 
treatment of, 566 
changes during pregnancy, 148 
their diagnostic value, 79 
glands, 146 

their sympathetic relations with the 
uterus, 80 
Mania, puerperal. See Insanity, ■ Puer- 
peral. 
Measles, affecting the foetus, 238 

in pregnancy, 221 
Meconium, 131 
Membranes, artificial rupture of, 284 

puncture of, as a means of inducing 
labor, 451 
Menstruation, 81 
cessation of, 93 
during pregnancy, 144 
changes in Graafian follicle after, 81 
period of, duration, and recurrence, 
87 



Menstruation — 

purpose of, 92 

source of blood in, 89 

theory of, 90 

quantity of blood lost in, 88 

vicarious, 92 
[Menstrual life, duration of, 94] 
Mesoblast, 105 
Milk, artificial human, 570 

ass's, 569 

cow's, and its preparation, 570 

defective secretion of, 564 

excessive secretion of, 565 

goat's, 570 

means of arresting the secretion of, 
563 

secretion of, after delivery, 560 

transfusion of, 539 
Milk-fever, 548 
Miscarriage. See Abortion. 
Missed labor, 193 
Moles, 245 
Monstrosity (double), 367 

classification of, 367 

mechanism of delivery in, 367 
Mons veneris, 49 
Montgomery's cups, 102 
Morning sickness, 145 
Mortality of childbirth, 546 
Mucous membrane of uterus. See Uterus. 
Miiller's operation, 526 
Myxoma fibrosum, 232 



VTERVOUS shock after delivery, 547 

JA Nervous system, changes in, during 
pregnancy, 141 
disorders of, in pregnancy, 211 
excitability of, in puerperal women, 
578 

Neuralgia in pregnancy, 211 

Nipple, 80 

Nipples, depressed, 564 

fissures and excoriations of, 564 

Nursing. See Lactation. 

Nutrition of foetus, 127 

Nymph?e. See Labia minora. 



OBLIQUELY contracted pelvis, 386 
Obstetric bag, 281 
Occipito-posterior positions, difficult cases 
of, 319 
causes of face-to-pubes delivery in, 

319 
[version by the vertex, 321] 
forceps in, 320 
treatment of, 319 
vectis or fillet in, 320 
Omphalo-mesenteric artery and vein, 107 
Opiates, use of, after delivery, 553 
[Opium to arrest labor in threatened abor- 
tion, 250] 
j Os innominatum, 33 
i Osteomalacia, as a cause of deformity, 376 



INDEX. 






Osteophytes, formation of, during preg- I 

nancy, 141 
Os uteri, constriction of internal, as a 
cause of dystocia. 355 
dilatation of, as a means of inducing 

labor, 453 
occlusion of, in labor, 354 
Ovarian pregnancy. See Extra-uterine 
Pregnancy. 
tumor in pregnancy, 224 
Ovariotomy in pregnancy. 224 
Ovary, 72 

functions of, 81 
structure of, 74 
vascular arrangements of, 78 
Ovule, 77 

changes in, after impregnation, 9S 
changes in, when retained in utero 

after its death, 245 
formation of, 75 
Ovum, blighted, retained in utero, 245 
Oxytocic remedies, 342 



PAINS, after-, 552 
false, 282 
irregular and spasmodic, as a cause of 

protracted labor, 341 
labor, 261 
Palpitation in pregnancy, 205 
Pampiniform plexus, 65 
Paralysis in pregnancy. 211 

from embolism of the cerebral arte- 
ries. 634 
from embolism of the main arteries 
of the limb, 634 
Parovarium, 69 
Parturient canal, axis of, 45 
Pathology of decidua and ovum, 227 
Pelvic cellulitis and peritonitis, 644 
etiology of, 645 
importance of, distinguishing the two 

forms of disease 6 1 1 
connection with septicaemia, 645 
opening of abscess in, 650 
prognosis of, 6 19 
relative frequency of the two forms 

of disease, 6 16 
results of physical examination, 617 
seat of inflammation in cellulitis, 

646 
seat of inflammation in peritonitis, 

646 
suppuration in. 6 18 
symptomatology, 6 17 
terminations of. 6 H 
treatment of, 6 19 
two distinct forms of disease 6 1 1 
Pelvic presentations, 299 

application oi forceps to the after- 
coming head iii 
causes of, 299 
danger to children in. 300 
diagnosis of, 300 
frequency of, 299 



Pelvic presentations — 

management of impacted breech in. 
308 

mechanism of, 302 

prognosis in, 299 

treatment of, 306 
Pelvimeters, various forms of, 392 
Pelvis, alterations in, articulations of. dur- 
ing pregnancy, 39 

anatomy of, 33 

articulations of, 36 

axes of, 45 

Csesarean section in deformitio of, 
398 

causes of deformity of, 375 

comparative estimate of turning and 
forceps in deformity of. 6'.»7 

craniotomy in deformity of, 398 

diagnosis of deformity, 391 

deformities of, 375 

development of, 46 

difference according to race. 47 

differences in the two sexes, 41 

division into true and false, 64 

equally contracted 677 

equally enlarged, 377 

flattened, 378 

forceps in deformity of, 395 

induction of premature labor in de- 
formity of, 398 

infantile. 16 

[ justo-minor in a large woman, 377] 

kyphotic 

ligaments of, 37 

funnel-shaped, 378 

masculine. 378 

mechanism of delivery in deformed, 
390 

movements of the articulation- 

obliquely-contracted, 385 

planes oi. 

Robert's, 387 

scoliotic. '■'>, '.» 

soft parts connected with, 48 

tumors of, -^ v 

turning in deformity of, 

undeveloped, 377 
Perchloride of iron, injections of, in post- 
partum hemorrhage, 126 
Perforation of after-coming head. 50 1 
Perforators, 198 
Perineum, distension of, in lab r 

incision of, 287 

laceration of, 

relaxation of, 

rigidity of, as a cause of protracted 
labor, 356 
Peritonitis, pelvic See Pelvic Celliditi*. 

\ |»uci-|'cral, venesection in, 618 ] 

puerperal. & iio. 

Phlegmasia dolens. See 1 /'■ 

I 
Placenta adhesion of after delivery, 119 
teration of. 1 H'> 

detachment of, in labor, 



660 



INDEX. 



Placenta — 

expression of, 291 

foetal portion of, 112 

form of, in man and animals, 111 

formation of, from chorion, 110 

functions of, 11Q 

maternal portion of, 114 

minute structure of, 112 

pathology of, 232 

sinus system of, 114 

sounds produced during separation of, 
156 

treatment of adherent, 423 

treatment of, in extra-uterine feta- 
tion, 188 
Placenta membranacea, 232 
Placenta praevia, 400 

causes of, 400 

causes of hemorrhage in, 403 

natural termination of labor in, 405 

pathological changes of placenta in, 
405 

prognosis in, 406 

sources of hemorrhage in, 403 

summary of rules for treatment in, 
410 

symptoms of, 403 

treatment of, 406 

turning in, 408 

[by Hicks' method, 411] 
Placentae succenturiae, 232 
Placentitis, 233 
Plugging of vagina, 252 
Plural births, 166, 363 

arrangement of placentae and mem- 
branes in, 168 

causes of, 167 

diagnosis of, 169 

relative frequency of, in different 
countries, 166 

sex of children in, 167 

treatment of, 363 
Pneumonia in pregnancy, 221 

puerperal embolic, 632 
" Polar globule," 99 
[Polypus obstructing labor, 362] 
Porro's operation, 525 
[Porro-Caesarean statistics, the latest, 526] 
Position of cranium in head presentation. 

See Head Presentations. 
Post-partum hemorrhage. See Hemor- 
rhage. 
Pregnancy, 132 

abnormal, 166 

affections of respiratory organs, 204 

alteration of color of vaginal mucous 
membrane, as a sign of, 152 

ballottement, as a sign of, 151 

changes in the blood during, 139 

changes in the liver, lymphatics, and 
spleen during, 141 

changes in the urine during, 142 

complicated with ovarian tumor, 224 

deposits of pigmentary matter during, 
148 



Pregnancy — 

diabetes in, 210 

differential diagnosis of, 157 

dress of patient in, 280 

duration of, 160 

enlargement of abdomen as a sign of, 
149 

extra-uterine. See Extra-uterine Prey- 
nancy. 

fcetal movements in, 149 

formation of osteophytes during, 141 

hypertrophy of the heart during, 141 

in cases of double uterus, 67 

in the absence of menstruation, 145 

intermittent uterine contractions, as a 
sign of, 150 . 

ptyalism in, 204 

prolapse of the uterus in, 216 

protraction, 163 

pruritus in, 215 

quickening, 149 

sickness of, 145 

signs and diagnosis of, 144 

sounds produced by the foetal move- 
ments in, 156 

spurious, 159 

sympathetic disturbances of, 145 

[tension of abdomen in, producing 
dyspnoea at night, how treated, 205] 

uterine fluctuation in, 151 

vaginal pulsation in, 151 

vaginal signs of, 151 
Premature labor, 242 

historv of the operation of induction 
of, 449 

induction of, 449 [456] 

induction of, in deformed pelvis, 398 

injection of carbonic acid gas as a 
means of inducing, 455 

insertion of flexible bougie as a means 
of inducing, 455 

objects of the operation of induction 
of, 449 

oxytocics as a means of inducing, 452 

period for the induction of, in de- 
formed pelvis, 399 

precautions as regards the child in the 
induction of, 456 

puncture of the membranes as a 
means of inducing, 451 

separation of the membranes as a 
means of inducing, 454 

vaginal and uterine douches as a 
means of inducing, 454 
Pressure as a means of inducing uterine 
contractions, 344 

mode of applying, 345 
Prolapse of umbilical cord. See Umbil- 
ical Cord. 
Ptyalism in pregnancy, 204 
Puerperal convulsions. See Eclampsia. 
Puerperal fever. See Septicemia. 
Puerperal mania. See Insanity. 
Puerperal state, 546 

after-treatment in, 556 



INDEX. 



661 



Puerperal state — 

diet and regimen in, 554 
diminution of uterus in, 549 
importance of prolonged rest in, 556 
pulse in, 547 

secretions and excretions in, 548 
temperature in, 548 

Pulmonary arteries, anatomical arrange- 
ment of, as favoring thrombosis, 
624 



Q 



UICKENING, 149 

Quinine as an oxytocic, 343 



RACE, as influencing the size of the 
foetal skull, 122 
Recto-vaginal fistula, 439 
Respiration of foetus, 128 
Retroversion of the gravid uterus, 217 
Rickets as a cause of pelvic deformity, 370 
Rosenmiiller, organ of. See Parovarium. 
Round ligaments of the uterus, 70 
Rules for monthly nurses, 556 
Rupture of uterus. See Uterus, 



SACRUM, anatomy of, 35 
mechanical relations, 35 
Salivation in pregnancy, 204 
Scarlet fever affecting the fetus, 238 
in pregnancy, 221 
in the puerperal state, 600 
Scoliotic deformity of pelvis, 379 
Scvbalae in the rectum obstructing labor, 

360 
Septicemia (puerperal), 593 
bacteria in, 605 
channels of diffusion in. 605 
through which septic matter may be 

absorbed, 5 ( .»7 
cold in treatment of, 619 
conduct of practitioner in regard to, 

604 
contagion from other puerperal pa- 
tients as a cause of. 602 
description of. 609 
division into auto-genetic and hetero- 

genetic forms, 598 
epidemics of. 595 
history of, 593 
importance of antiseptic precautions 

in. 604 

influence of cadaveric poison as a 
cause of, 598 

influence of zymotic disease in caus- 
ing, 600 

its connection with pelvic cellulitis 
and peritonitis, 6 15 

local changes in, 605 

malarial, 615 

mode in which the poison may be 
conveyed to patients in, 603 

mortality in lying-in hospitals, 594 



Septicaemia puerperal) — 

nature of septic poison, 605 

pathological phenomena in. 607 

prevention of, 604 

pyaemic forms of. 614 

sewer gas as a source of infection, 601 

sources of auto-infection in, " 

of hetero-infection. 598 

symptoms of the intense forms, 611 

theory of an essential zymotic fever, 
595 

of identitv with surgical septicaemia, 
596 

of local origin, 595 

transfusion of blood in. 536 

treatment of, 615 

venesection in. 618 

Warburg's tincture in the treatment 
of, 619 
Sex, discovery of, of fetus during preg- 
nancy, 153 

of foetus as influencing the size of the 
skull. 122 
Shoulder presentations. 322 

diagnosis of, 325 

division of, 323 

mechanism of, 327 

prognosis and frequency of. 325 

spontaneous version in. 327 

spontaneous evolution in. 328 

treatment of, 329 
Siamese twins, how born. 368 
Sickness of pregnancy, 1 15 
Smallpox anecting the foetus, 237 

in pregnancy, 221 
Smith's, Tyler, theory of labor, 257 
Spondylolisthesis, 381 [382] 
Spondylolizema, 382 
Spontaneous evolution, 328 

version. 327 

Spurious pregnancy, 159 
diagnosis of, 160 

BJ mptoms of. 159 

[Stethoscope, ( : aann's, 155] 

: Stillbirth, apparent, 557 
Symphyseotomy, 527 

| in [taly, revival of, 529 ] 

Syncope during or after labor, I 

in pregnancy, 205 

| postural treatment of) 126] 
Syphilid affecting the foetu 

a- a cause of abortion, 2 17 

in pregnancy, 222 
Sugar, in urine of pregnancy, l 18 
Super-fecundation and super-foetation, 169 
Sutures of foetal head, L20 



rpEMPEB \ I I 1 : 1 after delta i 
1 Thrombosis peripheral venous . 637 
changes in thrombi in, ,; 11 
condition of the affected limb 
detachment of emboli in, 641 

hi-tor\ and patholog3 Oi 

progress of the diai 



662 



INDEX. 



Thrombosis (peripheral venous) — 

symptoms of, 637 

treatment of, 641 

(puerperal), 621 

arterial thrombosis and embolism, 633 

cardiac murmur in pulmonary, 629 

cases illustrating recovery from pul- 
monary, 627-629 

causes of death in pulmonary, 630 

clinical facts in favor of pulmonary, 
625 

conditions which favor thrombosis in 
the puerperal state, 623 

distinction between thrombosis and 
embolism, 624 

phlegmasia dolens a consequence of, 
622 

post-mortem appearance of clots in 
pulmonary, 630 

pulmonary, as a cause of pleuro-pneu- 
monia, 632 

question of primary thrombosis in the 
pulmonary arteries, 624 

question of recovery from pulmonary, 
626 

symptoms of arterial, 633 

of pulmonary obstruction in, 626 

treatment of arterial, 634 

of pulmonary, 631 
Thrombosis of uterine vessels, 416 
Thrombus. See Hematocele. 
Toothache in pregnancy, 204 
Transfusion of blood, 534 

addition of chemical reagents to pre- 
vent coagulation of fibrin, 538 

cases suitable for the operation, 540 

dangers of the operation, 539 

defibrination of blood in, 543 

difficulties of the operation, 536 

effects of successful transfusion, 545 

history of the operation, 535 

immediate transfusion, 537 

method of injecting defibrinated 
blood, 544 

method of performing immediate 
transfusion, 541 

method of preparing defibrinated 
blood, 544 

nature and object of the operation, 
536 

Schiifer's directions for immediate, 
541 

secondary effects of, 545 

statistical results of, 539 
Tropics, influence of residence in, on 

labor, 339 
Trunk, presentation of. See Shoulder Pres- 
entations. 
Tumors, diagnosis of uterine and ovarian, 
158 

fetal, 239 

obstructing labor, 373 

(maternal) obstructing delivery, 358 
Tunica albuginea, 74 
Turning, 457 



Turning — 

after perforation, 505 

anaesthesia in, 462 

[bi-manual, of Hicks, in placenta 
praevia, 411] 

by combined method, 462 

by external manipulation only, 459 

cases suitable for the operation, 459 

operating by combined method, 458 

cephalic, 457 

choice of hand to be used, 462 

history of the operation, 457 

in abdomino-anterior positions, 469 

in deformed pelvis, 396 

in placenta praevia, 408, 468 

method of cephalic, 460 

of performing by external manipula- 
tion, 459 

of podalic, 466 

object and nature of the operation, 
458 

period when the operation should be 
performed, 462 

podalic, 461, 465 

position of patient in, 461 

statistics and dangers of, 458 

value of anaesthetics in difficult cases 
of, 470 
Twins. See Plural Births. 
Twins [Carolina, how born, 370] 

[Carolina, manner of birth of, 370] 

conjoined, 367 

[Hungarian, manner of birth of, 
370] 

locked, 364 

[Siamese, manner of birth of, 368] 

UMBILICAL cord, 117 
knots of, 117, 235 
ligature of, 289 
pathology of, 235 
prolapse of, 332 
cause of, 333 
prolapse of, diagnosis of, 333 
frequency of, 332 
postural treatment of, 334 
prognosis of, 333 
reposition of, 335 
treatment by laceration, 289 
Umbilical souffle, 155 

vesicle, 107 
Urachus, 108 

Uraemia, in connection with eclampsia, 
576 
in connection with puerperal insanity, 
586 
Urethra, 51 
Urine, changes in, during pregnancy, 112 

retention of, after delivery, 553 
Uterine fluctuation, as a sign of preg- 
nancy, 151 
souffle, 155 
Utero-sacral ligaments, 70 
Uterus, 56 



INDEX. 



663 



Uterus — 

analogy of interior of, after delivery, 
and stump of an amputated limb, 
105 

anomalies of, 67 

ante-partum hour-glass contraction, 
355 

arrangement of muscular fibres of, 61 

axis of, during pregnancy, 185 

changes in cervix during pregnancy, 
135, 136 

changes in form and dimensions of, 
during pregnancy, 133 

changes in mucous membranes of, af- 
ter delivery, 550 

changes in mucous membranes of, af- 
ter impregnation, 100 

changes in tissues of, during preg- 
nancy, 138 

changes in the vessels of, after deliv- 
ery, 550 

congestive hypertrophy of, 158 

contractions of, in labor, 259 

dimensions of, 58 

diminution in size of, after deliverv, 
549 

distension of, as a cause of labor, 256 

distension of, by retained menses, 
158 

fattv transformation of, after deliverv, 
550 

hour-glass contraction, 418 

intermittent contractions of, during 
pregnancy, 150 

internal surface of, 59 

inversion of, 442 

[inverted, spontaneous reposition of, 
447] 

[painful intermittent contractions of 
threatening abortion, 150] 

[partitioned, 68] 
differential diagnosis of, 444 
production of, 444 

results of physical examination in, 
443 

[rupture of, rational treatment of, 
441] 

symptoms of, 443 

treatment of, 446 

ligaments of, 68 

lymphatics of, 65 

malposition of, as a cause of pro- 
tracted labor, 341 

mode of action in labor, 259 

mucous membrane of, <>1 

muscular fibres of, 61 

nerves of, 67 

regional divisions of, 58 

relations of, 56 

retroversion of gravid, 217 



Uterus — 

rupture of, 431 

alterations of tissues in, 433 

causes of, A'.Vl 

comparative result of various methods 
of treatment in. 438 

prognosis of, 436 

seat of laceration in, 432 

symptoms of, 4:i5 

treatment of, 437 

gastrotomy in. 438 

size of, at various periods of preg- 
nancy, 134 

state of, in protracted labor. 339 

structures composing, 60 

utricular glands of, 62 

vessels of, 65 

weight of, alter delivery, 550 



VAGINA, 54 
bands and cicatrices of, obstructing 

delivery, 353 
contraction of, after delivery, 551 
lacerations of, 439 
orifice of, •">•_! 
structure of, 54 
Varicose veins in pregnancy, 215 
Vectis, 495 

action of, 496 

cases in which it is applicable, 496 
Veins, entrance of air into, as ;i cause of 
sudden death after delivery, 636 

Venesection for rigidity of cervix. 352 
Version. See Turning. 
Vesico-uterine ligaments, 71 
Vesico- vagina] fistula, l.'> ( .) 
Vestibule, 51 

Vicarious menstruation, 92 
Vomiting in pregnancy, 198 

Vulva, 18 

condition of, after deliver) . 551 
oedema of, obstructing labor, 360 
vascular supply of, 
Vulvo-vaginal glands, 52 



WARBURG'S tincture, 619 
Weaning. See Lactation. 
Wet-nurse, selection of, 561 
Wolffian bodies, 66, 1 18 
[ Womanhood, precocious physical, 86 I 
| Woman, puerperal, treatment • : 
Wounds of the foetus, 240 



Zo\ \ pellucida, 77 
Zymotic disease, affecting the foetus, 
2 
a- a cause of 9epti< eamia I 



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Lea Brothers & Co.'s Publications — Anatomy. 



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Medical Applied Anatomy. In one pocket-size 12mo. volume. 
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publication. See StwJ 



8 Lea Brothers & Co.'s Publications — Physiology, Chemistry. 



I> ALTON, JOHN C, M. I)., 

Professor of Physiology in the College of Physicians and Surgeons, New York, etc. 

A Treatise on Human Physiology. Designed for the use of Students and 
Practitioners of Medicine. Seventh edition, thoroughly revised and rewritten. In one 
very handsome octavo volume of 722 pages, with 252 beautiful engravings on wood. Cloth, 
$5.00 ; leather, $6.00 ; very handsome half Kussia, raised bands, $6.50. 



The merits of Professor Dalton's text-book, his 
smooth and pleasing style, the remarkable clear- 
ness of his descriptions, which leave not a chapter 
obscure, his cautious judgment and the general 
correctness of his facts, are perfectly known. They 
have made his text-book the one most familiar 
to American students. — Med. Record, March 4, 1882. 

Certainly no physiological work has ever issued 
from the press that presented its subject-matter in 
a clearer and more attractive light. Almost every 
page bears evidence of the exhaustive revision 
that has taken place. The material is placed in a 



more compact form, yet its delightful charm is re- 
tained, and no subject is thrown into obscurity. 
Altogether this edition is far in advance of any 
previous one, and will tend to keep the profession 
posted as to the most recent additions to our 
physiological knowledge. — Michigan Medical News, 
April, 1882. 

One can scarcely open a college catalogue that 
does not have mention of Dalton's Physiology as 
the recommended text or consultation-book. For 
American students we would unreservedly recom- 
mend Dr. Dalton's work.- Va. Med. Monthly, July ,'82. 



FOSTER, MICHAEL, M. B., F. B. S., 

Professor of Physiology in Cambridge University, England. 
Text-Book of Physiology. Third American from the fourth English edition, 
with notes and additions by E. T. Reichert, M. D. In one handsome royal 12mo. volume 
of over 1000 pages, with about 300 illustrations. In press. , 

A notice of the previous edition is appended. 



A more compact and scientific work on physiol- 
ogy has never Deen published, and we believe our- 
selves not to be mistaken in asserting that it has 
now been introduced into every medical college 
in which the English language is spoken. This 
work conforms to the latest researches into zoology 
and comparative anatomy, and takes into consid- 



eration the late discoveries in physiological chem- 
istry and the experiments in localization of Ferrier 
and others. The arrangement followed is such as 
to render the whole subject lucid and well con- 
nected in its various parts. — Chicago Medical Jour- 
nal and Examiner, August, 1882. 



FOWEB, JETENBT, M. B., F. B. C. 8., 

Examiner in Physiology, Royal College of Surgeons of England. 
Human Physiology. In one handsome pocket-size 12mo. volume of 396 pages, 
with 47 illustrations. Cloth, $1.50. See Students' Series o Manuals, page 3. 

as to place it within the reach of all, while the ex- 



This little work is deserving of the highest 
praise, and we can hardly conceive how the main 
facts of this science could have been more clearly 
or concisely stated. The price of the work is such 



cellence of its text will certainly secure for it most 
favorable commendation — Cincinnati Lancet and 
Clinic, Feb. 16, 1884. 



CABFENTEB, WM. B., M. L>., F. B. 8., F. G. 8., F. L. S. 9 

Registrar to the University of London, etc. 

Principles of Human Physiology. Edited by Henry Power, M. B., Lond., 
F. E. C. S., Examiner in Natural Sciences, University of Oxford. A new American from the 
eighth revised and enlarged edition, with notes and additions by Francis Gr. Smith, M. D., 
late Professor of the Institutes of Medicine in the University of Pennsylvania. In one 
very large and handsome octavo volume of 1083 pages, with two plates and 373 illus- 
trations. Cloth, $5.50 ; leather, $6.50 ; half Kussia, $7. 



FBANKLAND, F., I>. C.L., F. B.S., &JAFF, Flu JO., F. L C, 



Professor of Chemistry in the Normal School 
of Science, London. 



Assist. Prof, of Chemistry in the Normal 
School of Science, London. 



Inorganic Chemistry. In one handsome octavo volume of 500 pages, with 51 
woodcuts and 2 lithographic plates. In press. 



FOWNE8, GEOBGE, Fh. D. 

A Manual of Elementary Chemistry; Theoretical and Practical. Re- 
vised by Henry Watts, B. A., F. R. S. New American edition. In one large royal 12mo. 
volume of over 1000 pages, with 200 illustrations on wood and a colored plate. In press. 

A notice of the previous edition is appended. 

The book opens with a treatise on Chemical 
Physics, including Heat, Light, Magnetism and 
Electricity. These subjects are treated clearly 
and briefly, but enough is given to enable the stu- 
dent to comprehend the facts and laws of Chemis- 
try proper. It is the fashion of late years to omit 
these topics from works on chemistry, but their 
omission is not to be commended. As was required 
by the great advance in the science of Chemistry 



of late years, the chapter on the General Principles 
of Chemical Philosophy has been entirely rewrit- 
ten. The latest views on Equivalents, Quantiva- 
lence, etc., are clearly and fully set forth. This 
last edition is a great improvement upon its prede- 
cessors, which is saying not a little of a book that 
has reached its twelfth edition.— Ohio Medical Re- 
corder, Oct., 1878. 



Wohler's Outlines of Organic Chemistry. Edited by Fittig. Translated 
by Ira Remsen, M. D., Ph. D. In one 12mo. volume of 550 pages. Cloth, $3. 



Lea Brothers & Co.'s Publications — Chemistry. 9 



ATTEIELD, JOHN, P/i. D., 

Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc. 

Chemistry, General, Medical and Pharmaceutical; Including 1 
istry of the U. S. Pharmacopoeia. A Manual of the General Principles 
and their Application to Medicine and Pharmacy. A new American, from the tenth 

English edition, specially revised by the Author, "in one hail 
of 728 pages, with 87 illustrations. Cloth, $2.50; leather, - 

A text-book which passes through ten editions to pot himself in the ippre- 

in sixteen years must have good qualities. This oia of mind.— 

remark is certainly applicable to Attrield's Chem- nal, April, L884. 

It is a book on which too much pra 



istry, a book which is so well known that it 
hardly necessary to do more than note the appear- t ,. .'. 
ance of this new and improved edition. It seems, ia un8Ur| 
however, desirable to point out that feature of the science, and 
book which in all probability, has made U 



popular There can be little doubt that it is its mdi8p , 

thoroughly practical character the expression p art i,„.„- . 

being used in its best sense The author under- chemistry of tl oacopce 

stands what the student ought to learn, and is able cn \ \ j,, U rnal J a 



BLOXA3I, CHARLES L., 

Professor of Cliemistry in King's College, London. 

Chemistry, Inorganic and Organic. New American from the fifth Lon- 
don edition, thoroughly revised and much improved. In one very handsome octavo 
volume of 727 pages, with 292 illustrations, (loth, $3.75 ; leather, $4.75. J 

Comment from us on this standard work is al- I the best manuals of general chemistry m the Eng- 
most superfluous. It differs widely in scope and lish language. — D 

aim from that of Attfield, and in its way is equally I \i plan of this irork remains the 

beyond criticism. It adopts the most direct meth- ' same as In previons editions, I 
ods in stating the principles, hypotheses and facts being to ir i v . - dear and ■■■ 
of the science. Its language is so terse and lucid, | known elements and of their most im 
and its arrangement of matter so logical in se- compounds, with explanations <>f t 
quence that the student never has occasion to laws and principles involved. Ws gladly 



complain that chemistry is a hard study. Much 
attention is paid to experimental illustrations of 
chemical principles and phenomena, and the 
mode of conducting these experiments. The book 
maintains the position it has always held as one of 



now the opinion we exi 

edition, that tre regard Bloxam's Chemistry as 

one oi the best treatises on general and applied 



SIMON, W., Ph. JD., M. JD., 

Professor of Chemistry and Toxic, logy m the Collcgt 
Professor of Chemistry in the Maryland OoUcgt of Pharmacy, 

Manual of Chemistry. A Qnideto Lectures and Laboratory irork for Beginners 

in Chemistry. A Text-book, specially adapted for Students of Pharmacy and Medicine. 
In one 8vo. vol. of 410 pp., with L6 woodcuts ;m<l 7 plates, mostly of actual de] 
with colors illustrating 56 of the most important chetnio 

without plates, cloth, $2.50. Just ready. 
This book supplies a want long felt by stud.-! 
of medicine and pharmacy, and Is ;i ooncise but tatea of various reactions, form a novtd and uilu- 
thorough treatise on the subject. The long ex; kture of the l»»-k, and oannol I 
rience of the author as a teacher In schools of predated by l»'th student and 
medicine and pharmacy i- c in the over th< 
perfect adaptation of the work to the special needs Medico 
of the student of these branches. Th e colored I 

REMSEN, IRA, M. IK. Ph. O., 

Professor of Chemistry in th> 
Principles of Theoretical Chemistry, with ipa 1 • 
tion of Chemical Compounds. Second and revised edition, [none handsome royal l2mo, 
volume of 240 pages. Cloth, $1.75. J 

The book is a valuable contribution to theohen 

cal literature of instruction. That In bo fi 

a second edition lias been called for indicates ihnt Judh-i.. 

many chemical teachers have been found ready bin««d • 

to endorse its plan and to adopt its meth 

this edition a considerable proportion of tin- \» 

has been rewritten, much new ms 

added and the whole has been brought u| >Y.—Amenem 

We earnestly commend this bo 

WATTS, HENRY. B. /., F. B. 8 

Author of u A /' 

A Manual of Physical and Inorganic Cb 
of 500 pages, with L50 illustrations. P 

GALLOWAY'S QUALITATIVE ANALYSIS 

edition 
LEHMANN'S MANUAL OF CHEMICAL PHI 
IOLOGY. In one octavo volume of :v_7 pages, j : agea. mom, w com*. 

with 41 illustrations. Cloth.- 



10 



Lea Brothers & Co.'s Publications — Chemistry. 



CHARLES, T. CRANSTOVN, M. &., F. C. S., M. S., 

Formerly Asst. Prof, and Demonst. of Chemistry and Chemical Physics, Queen's College, Belfast. 

The Elements of Physiological and Pathological Chemistry. A 
Handbook for Medical Students and Practitioners. Containing a general account of 
Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and 
Excretions of the Body in Health and in Disease. Together with the methods for pre- 
paring or separating their chief constituents, as also for their examination in detail, and 
an outline syllabus of a practical course of instruction for students. In one handsome octavo 
volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. Just ready. 



The work is thoroughly trustworthy, and in- 
formed throughout by a genuine scientific spirit. 
The author deals with the chemistry of the diges- 
tive secretions in a systematic manner, which 
leaves nothing to be desired, and in reality sup- 
plies a want in English literature. The book ap- 
pears to us to be at once full and systematic, and 
to show a just appreciation of the relative import- 
ance of the various subjects dealt with. The work 
is written in a catholic spirit, and it contains refer- 
ences to all the best modern works. — British Medi- 
cal Journal, November 29, 1884. 

Dr. Charles is fully impressed with the import- 
ance and practical reach of his subject and he has 
treated it in a competent and instructive manner. 
We cannot recommend a better work than the 



present. In fact, it fills a gap in medical text- 
book s, a thing which can rarely be said nowadays. 
He devotes much space to urinary mysteries. He 
does this with much detail, yet in a practical and 
intelligible manner. In fact the author has filled 
his book with many practical hints. — Medical 
Record, Dec. 20, 1884. 

Dr. Charles' manual admirably fulfils its inten- 
tion of giving his readers on the one hand a sum- 
mary, comprehensive but remarkably compact, of 
the mass of facts in the sciences which have be- 
come indispensable to the physician ; and, on the 
other hand, of a system of practical directions so 
minute that analyses often considered formidable 
may be pursued by any intelligent person. — 
Archives of Medicine, Dec. 1884. 



MOFF3IANN, F., A.3L, Fh.JD., & POWER F.B., JPh.J)., 

Public Analyst to the State of New York. Prof, of Anal. Chem. in the Phil. Coll. of Pharmacy. 

A Manual of Chemical Analysis, as applied to the Examination of Medicinal 
Chemicals and their Preparations. Being a Guide for the Determination of their identity 
and Quality, and for the Detection of Impurities and Adulterations. For the use of 
Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceutical and 
Medical Students. Third edition, entirely rewritten and much enlarged. In one very 
handsome octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. 

tion of them singularly explicit. Moreover, it is 
exceptionally free from typographical errors. We 
have no hesitation in recommending it to those 



"We congratulate the author on the appearance 
of the third edition of this work, published for the 
first time in this country also. It is admirable and 
the information it undertakes to supply is both 
extensive and trustworthy. The selection of pro- 
cesses for determining the purity of the substan- 
ces of which it treats is excellent and the descrip- 



who are engaged either in the manufacture or the 
testing of medicinal chemicals. — London Pharma- 
ceutical Journal and Transactions, 1883. 



CLOWES, FRANK, I}. Sc, London, 

Senior Science- Master at the High School, New castle-under -Lyme, etc. 

An Elementary Treatise on Practical Chemistry and Qualitative 
Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and 
Colleges and by Beginners. Third American from the fourth and revised English edition. 
In one very handsome royal 12mo. volume of about 400 pages, with about 50 illustrations. 
In press. 

RALFE, CHARLES H., M. D., F. R. C. F., 

Assistant Physician at the London Hospital. 

Clinical Chemistry. In one pocket-size 12mo. volume of_314 pages, with 16 
illustrations. Limp cloth, red edges, $1.50. 
This is one of the most instructive little works 
that we have met with in a long time. The author 
is a physician and physiologist, as well as a chem- 
ist, consequently the book is unqualifiedly prac- 
tical, telling the physician just what he ought to 
know, of the applications of chemistry in medi- 



See Sivdevts , Series of 3Iovvols. page 3. 
cine. Dr. Ealfe is thoroughly acquainted with the 
latest contributions to his science, and it is quite 
refreshing to find the subject dealt with so clearly 
and simply, yet in such evident harmony with the 
modern scientific methods and spirit. — Medical 
Record, February 2, 1884. 



CLASSEN, ALEXANDER, 

Professor in the Royal Polytechnic School, Aix-la-Chapelle. 

Elementary Quantitative Analysis. Translated, with notes and additions, by 
Edgar F. Smith, Ph. D., Assistant Professor of Chemistry in the Towne Scientific School, 
University of Penna. In one 12mo. volume of 324 pages, with 36 illust. Cloth, $2.00. 



It is probably the best manual of an elementary 
nature extant insomuch as its methods are the 
best. It teaches by examples, commencing with 
single determinations, followed by separations, 



and then advancing to the analysis of minerals and 
such products as are met with in applied chemis- 
try. It is an indispensable book lor students in 
chemistry.— Boston Journal of Chemist? y, Oct. 1878. 



GREENE, WILLIAM H., 31. L>., 

Demonstrator of Chemistry in the Medical Department of the University of Pennsylvania. 
A Manual of Medical Chemistry. For the use of Students. Based upon Bow- 
man's Medical Chemistry. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75 

he recognition of compounds due to pathological 
onditions. The detection of poisons is treated 



It is a concise manual of three hundred pages, 
giving an excellent summary of the best methods 
of analyzing the liquids and solids of the body, both 
lor the estimation of their normal constituents and 



with sufficient fulness for the purpose of the stu- 
dent or practitioner.— Boston J I. of Chtm., June, '80 



Lea Brothers & Co.'s Publications— Pharm., Mat. MedL, Therap. 11 



PARRISH, EDWARD, 

Late Professor of the Theory and Practice of Pharmacy in the Philadelphia ColUge of Pharmacy. 

A Treatise on Pharmacy : designed as a Text-book far the Student 

Guide for the Physician and Pharmaceutist. With many Formulae and Pn 

Fifth edition, thoroughly revised, by Th Ph.G. in one handsome 

octavo volume of 1093 pages, with 256 illustrations. CI I 

No thoroughgoing pharmacist will fail to | s» ae This well-known work i .. based 

himself of so useful a guide to practice, and no upon the recently 

physician who properly estimates the value of an Each pag 

accurate knowledge of the remedial agents em- upon it. 

ployed by hirn in daily practice, bo far as their the rich store of the 

miseibihty, compatibility and most effective meth- all that ractical phai 

ods of combination are concerned, can afford to processes and dispei 

leave this work out of the list of their works of described vril - in its varioi 

reference. The country practitioner, who must as to afford aid and advice alike to the 

always be in a measure his own pharmacist, will to the practii . jujj. 

find it indispensable.— Louisville Medical News, ciously illustrated with g< .crican 

March 29, 188-1. Journal of Pharmacy, J.. 



BLERMANX, Dr. L., 

Professor of Physiology in the University of Zurich. 

Experimental Pharmacology. A Handbook of Meth rmining the 

Physiological Actions of Drugs. Translated, with the Author's permission, and with 
extensive additions, by Robert Meade Smith. M. D., Demonstrator of Physiology in the 

University of Pennsylvania. In one handsome llhno. volume oi 3. with '•'>- 

illustrations. Cloth, $1.50. 

Prof. Hermann's handbook, which Dr. Smith has plains the various methods and instrument 
translated and enriched with many valuable ad. li- and points out what lines 

tiona, will be gladly welcomed by those engaged in be | raued for -: dying mena, 

this department of physiology. It if it and also how and what particularly I 

little book, full of concise information, and it American Jon 
should find a place in every laboratory. It ex- 



MAISCET, JOHNM., Thar. D., 

Professor of Mai 

A Manual of Organic Materia Medica; Being a Guide to Materi 
the Vegetable and Animal Ki or the U» 

and Physic rw (second) edition. In one handsomer 

pages, with 242 illustrations. Cloth. $3.00. •/• ' ready. 

This work, though first published only three y< rt of print for fif- 

teen months, the author's Labors on the third edition of Zv 
prevented an earlier revision. The arrangement of the n 
unaltered, since the t< lias proved that it secore 

and practical applicability. In scope, the work has been enlarged by the introducti 
the drugs indigenous to North America and by a novel classification of the articles of the 
Materia Medica, according to their botanical 

accurate engravings add materially to the clearness of the ill hi lp to render the 

second edition even more serviceable than its pi 

BRUNTON, T. LAUDER, M. />., 

Lecturer on Materia Mi tUea and Ttu 

A Text-book of Pharmacology, Materia Med 
In one handsome octavo volume. In 

BRUCE, J. MITCHELL, M. D. f I\ R. < . P., 

Physician and I 
Materia Medica and Tl An Introducti 

ment. In one pocket-size 12mo. volume < ges. Limp 

See Student* Series of Mnminl.-. 

a^ one of the very : ■■■ i 

Medica and Therapeutics, replete with ii I 
tion abreast of the times, we unh. 

mend it as one of the very b 
medical student or practitioner of medicine. 
Cincinnati Medical Neio8 t k\\g 

Among the valaable new^Manus I 
of Medicine," one of the best is thai 
the public by Dr. Bruce. Bpeatinf 

GRIFFITH, ROBERT EGLESFIELD, M- D. 

A Universal Formulary, contoining the M 
tering Officinal and other Medicines. The whole ad 

ists. Third edition, thoroughly revised, with miniei 
Phar.D., Professor of and Botany in 1 

In one octavo volume of 775 pages, with 



12 Lea Brothers & Co.'s Publications — Mat. Med., Therap. 
STILLE, A., M. D., JLL. &., & 3IAISCH, J. M., JPhar.D., 

Professor Emeritus of the Theory and Prac- Prof, of Mat. Med. and Botany in Phila. 

tice of Medicine and of Clinical Medicine College of Pharmacy, Sec 'y to the Ameri- 

in the University of Pennsylvania. can Pharmaceutical Association. 

The National Dispensatory : Containing the Natural History, Chemistry, Phar- 
macy, Actions and Uses of Medicines, including those recognized in the Pharmacopoeias of 
the United States, Great Britain and Germany, with numerous references to the French 
Codex. Third edition, thoroughly revised and greatly enlarged. In one magnificent 
imperial octavo volume of 1767 pages, with 311 fine engravings. Cloth, $7.25 ; 
leather, $8.00; half Kussia, open back, $9.00. With Denison's "Keady Eeference Index" 
$1.00 in addition to price in any of above styles of binding. Just ready. 

In the present revision the authors have labored incessantly with the view of making 
the third edition of The National Dispensatory an even more complete represen- 
tative of the pharmaceutical and therapeutic science of 1884 than its first edition was of 
that of 1879. For this, ample material has been afforded not only by the new United 
States Pharmacopoeia, but by those of Germany and France, which have recently appeared 
and have been incorporated in the Dispensatory, together with a large number of new non- 
officinal remedies. It is thus rendered the representative of the most advanced state of 
American, English, French and German pharmacology and therapeutics. The vast amount 
of new and important material thus introduced may be gathered from the fact that the 
additions to this edition amount in themselves to the matter of an ordinary full- sized octavo 
volume, rendering the work larger by twenty-five per cent, than the last edition. The 
Therapeutic Index (a feature peculiar to this work), so suggestive and convenient to the 
practitioner, contains 1600 more references than the last edition — the General Index 
3700 more, making the total number of references 22,390, while the list of illustrations 
has been increased by 80. Every effort has been made to prevent undue enlargement of 
the volume by having in it nothing that could be regarded as superfluous, yet care has 
been taken that nothing should be omitted which a pharmacist or physician could expect 
to find in it. 

The appearance of the work has been delayed by nearly a year in consequence of the 
determination of the authors that it should attain as near an approach to absolute ac- 
curacy as is humanly possible. With this view an elaborate and laborious series of 
examinations and tests have been made to verify or correct the statements of the Pharma- 
copoeia, and very numerous corrections have been found necessary. It has thus been ren- 
dered indispensable to all who consult the Pharmacopoeia. 

The work is therefore presented in the full expectation that it will maintain the 
position universally accorded to it as the standard authority in all matters pertaining to 
its subject, as registering the furthest advance of the science of the day, and as embody- 
ing in a shape for convenient reference the recorded results of human experience in the 
laboratory, in the dispensing room, and at the bed-side. 

up to date. The work has been very well done, a 
large number of extra-pharmacopoeial remedies 
having been added to those mentioned in previous 
editions. — London Lancet, Nov. 22, 1884. 

Its completeness as to subjects, the comprehen- 
siveness of its descriptive language, the thorough- 
ness of the treatment of the topics, its brevity not 
sacrificing the desirable features of information 
for which such a work is needed, make this vol- 
ume a marvel of excellence. — Pharmaceutical Re- 



Comprehensive in scope, vast in design and 
splendid in execution, The National Dispensatory 
may be justly regarded as the most important work 
of its kind extaut. — Louisville Medical News, Dec. 
6, 1884. 

"We have much pleasure in recording the appear- 
ance of a third edition of this excellent work of 
reference. It is an admirable abstract of all that 
relates to chemistry, pharmacy, materia medica, 
pharmacology and therapeutics. It may be re- 
garded as embodying the Pharmacopoeias of the 
civilized nations of the world, all being brought 



cord, Aug. 15, 1884. 



FARQUHAHSOJST, KOBJEBT, M. 2>., 

Lecturer on Materia Medica at St. Mary's Hospital Medical School. 

A Guide to Therapeutics and Materia Medica. Third American edition, 
specially revised by the Author. Enlarged and adapted to the U. S. Pharmacopoeia by 
Frank Woodbury, M. D. In one handsome 12mo. volume of 524 pages. Cloth, $2.25. 



Dr. Farquharson's Therapeutics is constructed 
upon a plan which brings before the reader all the 
essential points with reference to the properties of 
drugs. It impresses these upon him in such away 
as to enable him to take a clear view of the actions 
of medicines and the disordered conditions in 
which they must prove useful. The double-col- 



umned pages— one side containing the recognized 
physiological action of the medicine, and the other 
the disease in which observers (who are nearly 



ways mentioned) have obtained from it good re- 
sults — make a very good arrangement. The early 
chapter containing rules for prescribing is excel- 



STILLE, ALFRED, M. I)., LL. D., 

Professor of Theory and Practice of Med. and of Clinical Med. in the Univ. of Penna. 
Therapeutics and Materia Medica. A Systematic Treatise on the Action and 
Uses of Medicinal Agents, including their Description and History. Fourth edition, 
revised and enlarged. In two large and handsome octavo volumes, containing 1936 pages. 
Cloth, $10.00 ; leather, $12.00 ; very handsome half Russia, raised bands, $13.00. 



We can hardly admit that it has a rival in the 
multitude of its citations and the fulness of its 
research into clinical histories, and we must assign 
it a place in the physician's library; not, indeed, 
as fully representing the present state of knowledge 



in pharmacodynamics, but as by far the most com- 
plete treatise upon the clinical and practical side 
of the question. — Boston Medical and Surgical Jour- 
nal, Nov. 5. 1874. 



Lea Brothers & Co.'s Publications— Pathol., Histol. 



13 



COATS, JOSEPH, 31. J>., F. F. P. S., 

Pathologist to the Glasgow Western Infirmary. 

A Treatise on Pathology. In one 
with 339 beautiful illustrations. Cloth, $5.50 

The work before us treats the subject of Path- 
ology more extensively than it is usually treated 
in similar works. Medical students as well as 
physicians, who desire a work for study or refer- 
ence, that treats the subjects in the various de- 
partments in a very thorough manner, but without 



prolixity, will certainly give this one the prefer- 
ence to any with which we are acquainted. It .sets 
forth the most recent discoveries, exhibits, in an 
interesting manner, the changes from a normal 



verv handsome octavo volume of 

; leather, $6.50. 

condition effected in st r u c tu res M, and 

points out the characteristics morbid 

agencies, so that they can be easily recognised. But, 

not limited to morbid anatomy,it explains fully how 

the functions of organs are disturbed by abnormal 

conditions. There is nothing I 

partment of medicine that is notas fully eh: 

as our present knowledge will admit.— Cincinnati 

Medical New. Oct. : 



GREEN, T. HENRY, 31. D., 

Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School, London. 

Pathology and Morbid Anatomy. Fifth American from the sixth 

and enlarged English edition. In one very handsome octavo volume of 482 pages, with 
150 tine engravings. Cloth, $2.50. Just ready. 

The fact that this well-known treatise has so No work in the English language Is BO admirably 
rapidly reached its sixth edition is a strong evi- adapted to the wai 
dence of its popularity. The author is to be con- tioner as this, and we would recommend il 

fratulated upon the thoroughness with which lie earnestly to every one. — Nashv 
as prepared this work. It is thoroughly abreast cine and S . Nov. 1884 

with all the most recent advances in pathology. | 



WOODHEAD, G. SI3LS, 31. JD., F. R. C. P. E., 

Demonstrator of Pathology in the University of Edinburgh. 

Practical Pathology. A Manual for Students and Practitioners. [non< 

tiful octavo volume of 497 pages, with 136 exquisitely colored illustrations. Cloth, $6.00. 

It forms a real guide for the student and practi- I The author merits all praise for havli 

tioner who is thoroughly in earnest in his en- a valuable work. — M 

deavor to see for himself and do for himself. To It Is manifestly the product of one who has him- 

the laboratory student it will be a helpful com- i self travel led over the whole field and whoiaskllled 

panion, and all those who may wish to familiarize noi merely in the art of hist 

themselves with modern methods of examining vatlon and interpretation of morl 



l>ut in the 
1 changes. The 
morbid tissues are strongly urged to provide t work Is BUre to command a wide circulation. It 
themselves with this manual. The numerous I should do much to enooui rsuit of path- 

drawings are not fancied pictures, or merely oloj I study 

schematic diagrams, but they represent faithfully have never 
the actual images seen under the miei L884. 



al study 

before I et, Jan. 



CORNIL, V., and RANJ r IER, L. 9 

Prof, in the Faculty of Med. of Paris. /' " met. 

A Manual of Pathological Histology. Translated, with notes and additions, 
by E. O. Shakespeare, M. 1)., Pathologist and Ophthalmi to Philadelphia 

Hospital, and by J. Henry C. Simes, M. 1)., Demonstrator of Pathological Histology in 
the University of Pennsylvania. In one very handsome octavo volume of , with 

360 illustrations. Cloth, $5.50 ; leather, $6.50 ; half Russia, raised bands, | 

Thus Bide by side physiological and 
anatomy K" hand In nand. afford Inn 
nil processes In demonstrations, com 



One of the most complete volumes on patholog- 
ical histology we haveever seen. The plan of study 
embraced within its pages Is essentially practical. 

Normal tissues are discussed, and after th<-ir thor- 
ough demonstration we are able to compare any 
pathological change which has occurred in them. 



dmirable arrangement of the work affords facility 
: the human 



KLEIN, E., 31. L>., F. />*. 8., 

Joint Lecturer ov < 

Elements of Histology, [n one pocket-sisel2mo. volume as, with 181 

illns. Limp cloth, red edges, 11.50. See&t 

Although an elementary work, it is by do meant 
superficial or incomplete, for the author | 
in concise language nearly all thefundamei 
regarding the microscopic structure of 



The Illustrations are numerous i 

commend l»r. Kl< li i Illy '" 

the stu 



PEPPER, A. J., 31. />., M. s., / . B. < . S.. 

Surgeo wrer ot - s7 - H ■■i»n. 

Surgical Pathology. In one pocket-sise L2mo. volume of 511 pages, with Bl 
illustrations. Limpcloth, red edges, $2.00. ><••> d* 

It is not pretentions, but it will 
ingly well asabook of ref.'r.-nre. It embodies a thai h nnnr 
great deal of matter, extending over the whole the *hole ran 
field of surgical pathology. Its form Is practi :al, ■■ 
its language Is clear, and the information 
forth is well-arrange. I, well-indexed and well- 

SCHAFER'S PRACTICAL IflSTm, 

handsome royal 12mo. volume of 308 pages, With « • •*■} OUWtO. Wl 

40 illustrations r-plate figures, plain and colored .. 

GLUGE'S ATLAS OF PATHOLOGICAL HISTOI. erfptlv< 



14 



Lea Brothers & Co.'s Publications — Practice of Med. 



I LINT, AUSTIN, 31. !>., 

Prof, of the Principles and Practice of Med. and of Clin. Med. in Bellevue Hospital Medical College, N. Y, 

A Treatise on the Principles and Practice of Medicine. Designed for 
the use of Students and Practitioners of Medicine. With an Appendix on the Researches 
of Koch, and their bearing on the Etiology, Pathology, Diagnosis and Treatment of 
Phthisis. Fifth edition, revised and largely rewritten In one large and closely-printed 
octavo volume of 1160 pages. Cloth, $5.50 ; leather, $6.50 ; half Eussia, $7. 

Koch's discovery of the bacillus of tubercle gives promise of being the greatest 
boon ever conferred by science on humanity, surpassing even vaccination in its benefits to 
mankind. In the appendix to his work, Professor Flint deals with the subject from a 
practical standpoint, discussing its bearings on the etiology, pathology, diagnosis, prog- 
nosis and treatment of pulmonary phthisis. Thus enlarged and completed, this standard 
work will be more than ever a necessity to the physician who duly appreciates the re- 
sponsibility of his calling. 



A well-known writer and lecturer on medicine 
recently expressed an opinion, in the highest de- 
gree complimentary of the admirable treatise of 
Dr. Flint, and in eulogizing it, he described it ac- 
curately as " readable and reliable." No text-book 
is more calculated to enchain the interest of the 
student, and none better classifies the multitudi- 
nous subjects included in it. It has already so far 
won its way in England, that no inconsiderable 
number of men use it alone in the study of pure 
medicine; and we can say of it that it is in every 
way adapted to serve, not only as a complete guide, 
but also as an ample instructor in the science and 
practice of medicine. The style of Dr. Flint is 
always polished and engaging. The work abounds 
in perspicuous explanation, and is a most valuable 
text-book of medicine. — London Medical News. 



This work is so widely known and accepted as 
the best American text-book of the practice of 
medicine that it would seem hardly worth while to 
give this, the fifth edition, anything more than a 
passing notice. But even the most cursory exami- 
nation shows that it is, practically, much more 
than a revised edition ; it is, in fact, rather a new 
work throughout. This treatise will undoubtedly 
continue to hold the first place in the estimation 
of American physicians and students. No one of 
our medical writers approaches Professor Flint in 
clearness of diction, breadth of view, and, what we 
regard of transcendent importance, rational esti- 
mate of the value of remedial agents. It is thor- 
oughly practical, therefore pre-eminently the book 
for American readers. — St. Louis Clin. Bee, Mar. '81. 



JBTABTSMOBNJE, HENBY, 31. D., 

Lately Professor of Hygiene in the University of Pennsylvania. 

Essentials of the Principles and Practice of Medicine. A Handbook 

for Students and Practitioners. Fifth edition, thoroughly revised and rewritten. In one 

royal 12mo. volume of 669 pages, with 144 illustrations. Cloth, $2.75 ; half bound, $3.00. 

Within the compass of 600 pages it treats of the I this one; and probably not one writer in our day 

history of medicine, general pathology, general | had a better opportunity than Dr. Hartshorne for 



symptomatology, and physical diagnosis (including 
laryngoscope, ophthalmoscope, etc.), general ther- 
apeutics, nosology, and special pathology and prac- 
tice. There is a wonderful amount of information 
contained in this work, and it is one of the best 
of its kind that we have seen. — Glasgow Medical 
Journal, Nov. 1882. 

An indispensable book. No work ever exhibited 
a better average of actual practical treatment than 



condensing all the views of eminent practitioners 
into a 12mo. The numerous illustrations will be 
very useful to students especially. These essen- 
tials, as the name suggests, are not intended to 
supersede the text-books of Flint and Bartholow, 
but they are the most valuable in affording the 
means to see at a glance the whole literature of any 
disease, and the most valuable treatment. — Chicago 
Medical Journal and Examiner, April, 18S2. 



BBISTOWB, JOHN SYEB, 31. D., F. B. C. !>., 

Physician and Joint Lecturer on Medicine at St. Thomas' 1 Hospital. 
A Treatise on the Practice of Medicine. Second American edition, revised 
by the Author. Edited, with additions, by James H. Hutchinson, M.D., physician to the 
Pennsylvania Hospital. In one handsome octavo volume of 1085 pages, with illustrations. 
Cloth, $5.00 ; leather, $6.00 ; very handsome half Eussia, raised bands, $6.50. 



The reader will find every conceivable subject 
connected with the practice of medicine ably pre- 
sented, in a style at once clear, interesting and 
concise. The additions made by Dr. Hutchinson 



are appropriate and practical, and greatly add to 
its usefulness to American readers. — Buffalo Med- 
ical and Surgical Journal, March, 1880. 



WATSON, SIB TH03IAS, M. D., 

Late Physician in Ordinary to the Queen. 

Lectures on the Principles and Practice of Physic. A new American 
from the fifth English edition. Edited, with additions, and 190 illustrations, by Henry 
Hartshorne, A. M., M. D., late Professor of Hygiene in the University of Pennsylvania. 
In two large octavo volumes of 1840 pages. Cloth, $9.00 ; leather, $11.00. 



LECTURES ON THE STUDY OF FEVER. By 
A. Hudson, M. D., M. R. I. A. In one octavo 
volume of 308 pages. Cloth, $2.50. 

STOKES' LECTURES ON FEVER. Edited by 
John William Moore, M. D.,"F. K. Q. C. P. In 
one octavo volume of 280 pages. Cloth, $2.00. 



A TREATISE ON FEVER. By Robert D. Lyons, 
K. C. C. In one 8vo. vol. of 354 pp. Cloth, $2.25. 

LA ROCHE ON YELLOW FEVER, considered in 
its Historical, Pathological, Etiological and 
Therapeutical Relations. In two large and hand- 
some octavo volumes of 14G8 pp. Cloth, $7.00. 



A CENTURY OF AMERICAN MEDICINE, 1776—1876. By Drs. E. H. Clarke, H. J. 
Bigelow, S. D. Gross, T. G. Thomas, and J. S. Billings. In one 12mo. volume of 370 pages. Cloth, $2.25. 



Lea Brothers & Co.'s Publications— Systems of Med. 15 



For Sale by Subscription Only. 



A System of Practical Medicine. 

BY AMERICAN AUTHOJ 

Edited by WILLIAM PEPPEli, M. D., LL. D., 

PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MED1 OF 

CLINICAL MEDICINE IN THE I > UjM A N i A . 

Assisted by Louis Starr, M. D., Clinical Professor of the Mb bildren in the 

Hospital of the University of Pennsylvania, 

In five imperial octavo volumes, containing about 1100 pages each, with W per 

volume, cloth, $5 ; leather, $6 ; half Russia, raised b -'. Vol 

(General Pathology, Sanitary Science and General 

with 24 illustrations and is just reach/. Volume If. wUl 

and the subsequent volumes at intervals of four months thereafter. 

The publishers feel pardonable pride in announcing this t work. 

three years it has been in active preparation, and it is now in a sufficient state of forward- 
ness to justify them in calling the attention of the profession t»» it as the work in which 
for the first time American medicine will be thoroughly represented by its worthiest 
teachers, and presented in the full development <>t" the practical utility which 
preeminent characteristic. The most able men — from the East and the West, from the 
North and the South, from all the prominent centres of education, and from all the 
hospitals which afford special opportunities of study and practice — have united in 
generous rivalry to bring together this vast aggri viali/cd experit 

The distinguished editor has so apportioned the work thai each author bai had 
assigned to him the subject which he is peculiarly fitted to rlwcnflB, and in which hi> 
will be accepted as the latest expression of scientific and practical knowi 
practitioner will therefore find these volumes a complete, authoritative and unfailing work 
of reference, to which he may at all times turn with lull certainty of finding what la- 
in its most recent aspect, whether he seeks information on J principli 
cine, or minute guidance in the treatment of special discs 

work that, with the exception of midwifery and matters strictly Burgicalj it embraces t la- 
whole domain of medicine, including the departments for which the ph; 
to rely on special treatises, such as diseases of women and children, of the genito-urinary 
organs, of the skin, of the nerves, hygiene and sanitarj nd medical ophthaln 

and otology. Moreover, authors have inserted the formulas which they have found 
efficient in the treatment of the various affections. it may thus be truly n 
Complete Library of Practical Mediciki 1 practitioner po«H«*ing it 

may feel secure that he will require little else in the daily round ol 

In spite of every effort to condense the rael amount of practical Information fur- 
nished, it has been impossible to present it in less than 5 I 
about 5500 beautifully printed pages, and embodying the matter of about 
octavos, illustrations will be introduced wherever tiny serve to elucidate 

As material for the work is substantially complete in the hands ol the editor, tl 
fession may confidently await the a] I the remainii upon th. 

above specified. A detailed prospecto* of the work will I appli- 

cation to the publish* 

There are certain elements of novelty about I 
extensive undertaking which can 
commend it to the medical public. It 
tobeastudv of diseases from the 
American practitioners and teacl 
be obtained bj a series of monogi 
by the mosteminent American phy»ici.iri 
of their own choosing, and hence I 
they are most Interested. I i rtainlj no ithei | i 

REYNOLDS, J. BUSSELL, M. />.. 

Professor of the i 

A System of Medicine. With 
A M M D.,late Professorof Hygiene in the Univ< 

and handsome octavo volumes, contain..), 

tions. Price per volume, cloth, \ 

$6.50. Per set, doth, |15; leather, $18; ball 

There is no modi. -id work which we have 



times past more frequently and hilly consult} I 

when perplexed by doubtaae to treatment, 

having unusual or apparently inexp 

toms presented to us, than *R 

Medicine." It contains just that kind of Informa 

tion which the busy practitioner frequently fin i 



16 



Lea Brothers & Co.'s Publications — Clinical Med., etc. 



FOTHFBGIBB, J. M., 31. B. 9 Fdin., 3f. B. C. B., Lond., 

Physician to the City of London Hospital for Diseases of the Chest. 

The Practitioner's Handbook of Treatment ; Or, The Principles of Thera- 
peutics. Second edition, revised and enlarged. In one very handsome octavo volume of 651 
Cloth, $4.00 ; very handsome half Russia, raised bands, $5.50. 

of physiology. Every chapter, every line, has the 
impress of a master-hand; and while the work is 
thoroughly scientific in every particular, it presents 
to the thoughtful reader all the charms and beau- 
ties of a well-written novel. No physician can 
well afford to be without this valuble work, for its 
originality makes it fill a niche in medical litera- 
ture hitherto vacant. — Nashville Journ. of Med. and 
Surg., Oct. 1880. 



The junior members of the profession will find 
it a work that should not only be read but care- 
fully studied. It will assist them in the proper 
selection and combination of therapeutical agents 
best adapted to each case and condition, and 
enable them to prescribe intelligently and success- 
fully. — St. Louis Courier of Medicine, Nov. 1880. 

The author merits the thanks of every well-edu- 
cated physician for his efforts toward rationalizing 
the treatment of diseases upon the scientific basis 



FLINT, AUSTIN, M. D. 

Clinical Medicine. A Systematic Treatise on the Diagnosis and Treatment of 
Diseases. Designed for Students and Practitioners of Medicine. In one large and hand- 
some octavo volume of 799 pages. Cloth, $4.50 ; leather, $5.50 ; half Russia, $6.00. 



It is here that the skill and learning of the great 
clinician are displayed. He has given us a store- 
house of medical knowledge, excellent for the stu- 
dent, convenient for the practitioner, the result of 
a long life of the most faithful clinical work, col- 
lected by an energy as vigilant and systematic as 
untiring, and weighed by a judgment no less clear 
than his observation is close. — Archives of Medicine, 
Dec. 1879. 

To give an adequate and useful conspectus of the 
extensive field of modern clinical medicine is a task 
of no ordinary difficulty; but to accomplish this con- 



sistently with brevity and clearness, the different 
subjects and their several parts receiving the 
attention which, relatively to their importance, 
medical opinion claims for them, is still more diffi- 
cult. This task, we feel bound to say, has been 
executed with more than partial success by Dr. 
Flint, whose name is already familiar to students 
of advanced medicine in this country as that of 
the author of two works of great merit on special 
subjects, and of numerous papers exhibiting much 
originality and extensive research. — The Dublin 
Journal, Dec. 1879. 



By the Same Author. 

Essays on Conservative Medicine and Kindred Topics. In one very hand- 
some royal 12mo. volume of 210 pages. Cloth, $1.38. 

BBOABBFNT, W. H., M. I>., F. B. C. B. 9 

Physician to and Lecturer on Medicine at St. Mary's Hospital. 
The Pulse. In one 12mo. volume. See Series of Clinical Manuals, page 3. 

SCBEBFIBFB, JDB. JOSFBH. 

A Manual of Treatment by Massage and Methodical Muscle Ex- 
ercise. Translated by Walter Mendelson, M. D., of New York. In one handsome 
octavo volume of about 300 pages, with about 125 fine engravings. Preparing, 



FIJSTLATSON, JAMFS, M. B. 9 Editor, 

Physician and Lecturer on Clinical Medicine in the Glasgow Western Infirmary, etc. 
Clinical Diagnosis. A Handbook for Students and Practitioners of Medicine. 
With Chapters by Prof. Gairdner on the Physiognomy of Disease ; Prof. Stephens on 
Diseases of the Female Organs ; Dr. Kobertson on Insanity ; Dr. Gemmell on Physical 
Diagnosis ; Dr. Coats on Laryngoscopy and Post-Mortem Examinations, and by the Editor 
on Case-taking, Family History and Symptoms of Disorder in the Various Systems. In 
one handsome 12mo. volume of 546 pages, with 85 illustrations. Cloth, $2.63. 



This is one of the really useful books. It is at- 
tractive from preface to the final page, and ought 
to be given a place on every office table, because it 
contains in a condensed form all that is valuable 
in semeiology and diagnostics to be found in 



bulkier volumes; and because of its arrangement 
and complete index it is unusually convenient for 
quick reference in any emergency that may come 
upon the busy practitioner. — N. C. Med. Journ., 
Jan. 1879. 



FFNWICK, SAMTJFL, M. !>., 

Assistant Physician to the London Hospital. 

The Student's Guide to Medical Diagnosis. From the third revised and 
enlarged English edition. In one very handsome royal 12mo. volume of 328 pages, with 
87 illustrations on wood. Cloth, $2.25. 



TAJnfFB, THOMAS HAWKFS, 31. B. 

A Manual of Clinical Medicine and Physical Diagnosis. Third American 
from the second London edition. Revised and enlarged by Tilbury Fox, M. D., Phy- 
sician to the Skin Department in University College Hospital, London, etc. In one small 
12mo. volume of 362 pages, with illustrations. Cloth, $1.50. 



STURGES' INTRODUCTION TO THE STUDY 
OF CLINICAL MEDICINE. Being a Guide to 
the Investigation of Disease. In one handsome 
12mo. volume of 127 pages. Cloth, 81.25. 

DAVIS' CLINICAL LECTURES ON VARIOUS 



IMPORTANT DISEASES; being a collection of 
the Clinical Lectures delivered in the Medical 
Ward of Mercy Hospital, Chicago. Edited by 
Frank H. Davis, M. D. Second edition. In one 
royal 12mo. volume of 287 pages. Cloth, $1.75. 



Lea Brothers & Co.'s Publications — Hygriene, Electa*., Tract. V 



RICHARJDSON r , B. W., M.A., M.D., LL. I)., JT.R.S.. F.S.A. 

Fellow of the Royal College of Physicians, London. 

Preventive Medicine. In one octavo volume oi H\ leather, 

$5; very handsome half Russia, raised bands, $5.50. 

Dr. Richardson has succeeded in producing a the question' 
work which is elevated in con 

sive in scope, scientific in character, systematic in e : _ \ and the pn 

arrangement, and which is written in*a clear, con- advised are accurate 
cise and pleasant manner. He evinces the happy .1 

faculty of extracting the pith of what is known on Thia is a book that will surely rind a 
the subject, and of presenting it in a most simple, table of eve I i the 

intelligent and practical form. There is perhaps medical profession, whose durj 
no similar work written for the general public pr< 
thatcontains such acomplete, reliable and instruc- 

tive collection of data upon the diseases common Thet: I. valu- 

to the race, their origins, causes, and the measures able hygienic information. — M 
for their prevention. The descriptions of 384, 

are clear, chaste and scholarly ; the discussion of i 



BARTHOLOW, ROBERTS, A. XL, M. />.. LL. />.. 

Prof, of Materia Medico, and General Therapeutics in 

Medical Electricity. A Practical Treatise on the Applicati tricity 

to Medicine and Surgery. Second edition. In one very handsome octavo volume 

pages, with 109 illustrations. Cloth. $S 

The second edition of this work following bo A most excellent work, 

soon upon the first would in itself appear to be a tioner to his fellow-pra- 

sufficient announcement; nevertheless, the text thoroughly practical. The work now before us 
has been so considerably revised and condensed, has the exceptional merit of dearly pointin 
and so much enlarged by the addition of new mat- where the ben. -tit- to be derived from electricity 
ter, that we cannot fail to recognize a vast im pro v. me. It contains all and everything that 
ment upon the former work. The author has pre- ' the practitioner needs in i id in- 
pared his work for students and practitioners— for telligently the natui 
those who have never acquainted themselves wit h making use of, and for it- proper a 
the subject, or, having done so, find that after a practice. In a condensed, practical form, 
timetheir knowledge needs refreshing. We think sents to the physician all 
he has accomplished this object. The book is not remember after peruainga whole library on n 
too voluminous, but is thoroughly practical, sim- electrioity, including the result 
pie, complete and comprehensible. It is, more- j vesications. It i- Ens book for the | 
over, replete with numerous illustrations of instru- and 

ments, appliances, etc.— Medical Record, November it has been appreciated I 

15, 1882. cian and Surgeon, Dee. 1883 



THE YEAR-BOOK OF TREATMENT. 

A Comprehensive and Critical Review for Practitioners of Medi- 
cine. In one 12mo. volume (.1' 320 pages, bound in limp cloth, with red • 

This work presents to the practitioner not only ;i complete classified si 
the more important advances made in the treatment of Disease during the y< 
Sept. 30, 1884, bin also a critical review of the same by ■ competent authority. 1 
department of practice hae been fully and concisely treated, and into the consideration oi 
each subject enter such allusion- to recehl pathological and clinical work aa bear directly 
upon treatment. As the medical literature of all countries has been placed under contri- 
bution, the references given throughout the work, together with tl 
subjects and authors, will serve as a -wide for those who desire to investigate anj thera- 
peutical topic at greater Length. 

The contributions arc from the pens of the following well-known gentlem* 
Mitchell Bruce, M.D.; T. Lattdi s, M.D., 

CS • F. If. CH LMPNEY8, M.B. ; An 

Dyce Duckwobth, M.D.; Geoboi P. Field, m I 

C.8. ; J. Warrington Hawab 3.: F. A. Mahomed, MB.; M > 

FRC.S., Ed.: Edmund Owen, F.B 

M.B., F.R.< .8.; C. II. Ralfe, M.D.; A. B. £ M.P.; 1 

Walter G. Smith. M.h. : J. Knowslei I 

F.B.C.S.; A. m: \v.\-i ■ i i-.vi i.i.i . M.l». : Johj Wl M D. 

LTABEBS/fON. S. ().. M. />.. 

Senior Physician to and lot* I 
On the Diseases Of the Abdomen; Comp 
other parts of the Alimentary ( anal,(Eao| I 

American from third enlarged and h Mmon. In 

volume of 564 pages, with illustration-. Cloth, I 

PAVY'S TREATISE ON THE 



GESTH >N; its D 

From the second London edition, [none 

volume of 238 pages. Cloth, |2.00. 

HAMBERS' MANUAL OF DIET AN1 

IN 111- \LTIi \ N '1» SK 
some octavo volume of 302 pp. 



From the second London edition. inon< 

volume of 238 pages. Cloth, - 

CHAMBERS* MANUAL OF DIET AND R1 
IN HEALTH AND SICKNESS 



18 Lea Brothers & Co.'s Publications — Throat, Lungs, Heart. 



COHEN, i. solis, m. l>„ 

Lecturer on Laryngoscopy and Diseases of the Throat and Chest m the Jefferson Medical College. 

Diseases of the Throat and Nasal Passages. A Guide to the Diagnosis and 
Treatment of Affections of the Pharynx, (Esophagus, Trachea, Larynx and Nares. Third 
edition, thoroughly revised and rewritten, with a large number of new illustrations. In 
one very handsome octavo volume. Preparing. 



SEILEM, CAUL, M. D., 

Lecturer on Laryngoscopy in the University of Pennsylvania. 

A Handbook of Diagnosis and Treatment of Diseases of the Throat, 
Nose and Naso-Pharynx. Second edition. In one handsome royal 12mo. volume 
of 294 pages, with 77 illustrations. Cloth, $1.75. 

It is one of the best of the practical text-books 
on this subject with which we are acquainted. The 
present edition has been increased in size, but its 
eminently practical character has been main- 
tained. Many new illustrations have also been 
introduced, a case-record sheet has been added, 
and there are a valuable bibliography and a good 
index of the whole. For any one who wishes to 
make himself familiar with the practical manage- 
ment of cases of throat and nose disease, the book 
will be found of great value. — New York Medical 
Journal, June 9, 1883. 

The work before us is a concise handbook upon 



the essentials of diagnosis and treatment in dis- 
eases of the throat and nose. The art of laryngos- 
copy, the anatomy of the throat and nose and the 
pathology of the mucous membrane are discussed 
with conciseness and ability. The work is pro- 
fusely illustrated, excels in many essential feat- 
ures, and deserves a place in the office of the 
practitioner who would inform himself as to the 
nature, diagnosis and treatment of a class of dis- 
eases almost inseparable from general medical 
practice. With advanced students the book must 
be very popular on account of its condensed style. 
— Louisville Medical News, June 26, 1883. 



BKOWNE, LENNOX, F. B. C. $., Edin., 

Senior Surgeon to the Central London Throat and Ear Hospital, etc. 
The Throat and its Diseases. Second American from the second English edi- 
tion, thoroughly revised. With 100 typical illustrations in colors and 50 wood engravings, 
designed and executed by the Author. In one very handsome imperial octavo volume of 
about 350 pages. Preparing. 

FLINT, AUSTIN, M. D., 

Professor of the Principles and Practice of Medicine in Bellevue Hospital Medical College, N. Y. 

A Manual of Auscultation and Percussion ; Of the Physical Diagnosis of 
Diseases of the Lungs and Heart, and of Thoracic Aneurism. Third edition. In one hand- 
some royal 12mo. volume of 240 pages. Cloth, $1.63. Now ready. 

It is safe to say that there is not in the English the results of his careful study and ample ex- 
language, or any other, the equal amount of clear, perience in such wise that the young will rind itthe 
exact and comprehensible information touching best source of instruction, and the old the most 
the physical exploration of the chest, in an equal pleasant means of reviving and complementing 
number of words. Professor Flint's language is their knowledge. — American Practitioner, June, 
precise and simple, conveying without dubiety 1883. 



BY THE SAME AUTHOR. 

Physical Exploration of the Lungs by Means of Auscultation and 
Percussion. Three lectures delivered before the Philadelphia County Medical Society, 
1882-83. In one handsome small 12mo. volume of 83 pages. Cloth, $1.00. 



A Practical Treatise on the Physical Exploration of the Chest and 
the Diagnosis of Diseases Affecting the Respiratory Organs. Second and 
revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. 

Phthisis: Its Morbid Anatomy, Etiology, Symptomatic Events and 
Complications, Fatality and Prognosis, Treatment and Physical Diag- 
nosis ; In a series of Clinical Studies. In one handsome octavo volume of 442 pages. 
Cloth, $3.50. 

A Practical Treatise on the Diagnosis, Pathology and Treatment of 
Diseases of the Heart. Second revised and enlarged edition. In one octavo volume 
of 550 pages, with a plate. Cloth, $4. 



GROSS, 8. JD., M.L>., LL.D., D.C.L. Oxon., LL.D. Cantab. 

A Practical Treatise on Foreign Bodies in the Air-passages. 

octavo volume of 452 pages, with 59 illustrations. Cloth, $2.75. 



In one 



FULLER ON DISEASES OF THE LUNGS AND 
AIR- PASSAGES. Their Pathology, Physical Di- 
agnosis, Symptoms and Treatment. From the 
second and revised English edition. In one 
octavo volume of 475 pages. Cloth, $3.50. 

SLADE ON DIPHTHERIA; its Nature and Treat- 
ment, with an account of the History of its Pre- 
valence in various Countries. Second and revised 
edition. In one 12mo. vol., pp. 158. Cloth, $1.25. 

WALSHE ON THE DISEASES OF THE HEART 
AND GREAT VESSELS. Third American edi- 
tion. In 1 vol. 8vo., 416 pp. Cloth, $3.00. 



SMITH ON CONSUMPTION; its Early and Reme- 
diable Stages. 1 vol. 8vo., pp. 253. Cloth, $2.25. 

LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490 
pages. Cloth, $3.00. 

WILLIAMS ON PULMONARY CONSUMPTION; 
its Nature, Varieties and Treatment. With an 
analysis of one thousand cases to exemplify its 
duration. In one 8vo. vol. of 3<)3 pp. Cloth, $2.50. 

CLINICAL OBSERVATIONS ON FUNCTIONAL 
NERVOUS DISORDERS, by C. Handfiei.d Jones, 
M. D. Second American edition. In one hand- 
some octavo volume of 340 pages. Cloth, $3.25. 



Lea Brothers & Co.'s Publications — Nerv. and Blent* i>i>., etc li* 
MITCHELL, S. WEIB, M. D., 

Physician to Orthopaedic Hospital and the Infirmary for Diseases of the Nervous System, Phi 

Lectures on Diseases of the Nervous System liy in Women. 

Second edition. In one 12mo. volume of 28 

So great have been the achievements of the system 
ment of hysterical and nervous diseases that the profession will welcome ti 
of a work which gives in detail the methods of enforced rest, mas 
on which this mode of treatment is .y of these led 

well-known diseases, and others deal with subjects which have been bith ted in 

medical literature or which are almost unknown to it. The present edition 
new lectures, notably those on the difficulties of diagnosis in hysterical diseases of joil 
the relations of hysteria to organic disease of the Bpine, and on hysterical d 
the rectum. 

HAMILTON, ALLAJV McLAXE, M. !>., 

Attending Physician at the Hospital for Epileptics and Paralytics, BlackwdCs Aland, N. T. 

Nervous Diseases ; Their Description and Treatment. Second edition, thoroughly 

revised and rewritten. In one octavo volume of . with 72 illustrati 

When thefirstedition of this good book appear, 
we gave it our emphatic endorsement, and the any Language, which i> a hand 
present edition enhances our appreciation of the from an rce. The in 

book and its author as a safe guide to students oi new edition, and the additions to it, will juai 
clinical neurology. One of the I old.— 

critical of English neurological journal.-, E Alienist and Neurologist, April, I 

TUKE, HAJSLEL HACK, JL JJ., 

Joint Author of The Manual of Psychological Medicine, etc. 

Illustrations of the Influence of the Mind upon the Body in Health 
and Disease. Designed to elucidate the Action of the Imaginatio Lition. 

Thoroughly revised and rewritten, in one handsome octavo toIud with 

two colored plates. Cloth, $3.00. 

It is impossible to peruse these interesting cha nlight- 

ters without being convinced of the author's per- ened deduction, the author 
feet sincerity, impartiality, ami thorough mental pc 
grasp. Dr. Tuke has exhibited 
amount of scientific address on all o 
the more intricate the phenomena tl ly commi 

has he adhered to a physiological and rational L 

CLOUSTOX, THOMAS 8., )/. />.« F. B. €. /'.. L. B. C. 8., 

Lecturer on Ment a ''!"'• 

Clinical Lectures on Mental Diseases. With an Appendix, contain! 
Abstract of the Statutes of the United States and of 
latingto the Custody of the Era 

of Mental Diseases", Medical Department ird I niversity. In one ban 

octavo volume of 541 pages, illustrated with eight lithographic plates, four ol which 
are beautifully colored. Cloth, * 1. 

The practitioner as well as the student will a 
cept the plain, practical teaching of the author a 



will nm 



forward 'step in the literature of insanity. iy obecu 

refreshing to find a physician of Dr. Clousl 

experience and high reputation giving the i 

side notes upon which his expenenci 

founded and his mature Judgment established. - 

Such cdiuical observations cannot hut !»• Useful to 

m — 
FOLSOM, CHARLES E.. '/• P., 

Assistant Professor of U 

An Abstract of the Stat. 
States and Territories relating 1 
pages. Cloth, $1.60. 

SAVAGE, GEORGE H.< Mi />.. 

Insanity and Allied Nei 
ume of Sli-4s, with 18 typical D 
Clinical Manuals, page '■'>. 

BLAYFAIll* M. 8., )/. D., I • /.'• C* P., 

The Systematic Trc.r u In 

one handsome small 12mo.voli 

"Rlnndford on Insanity and 

Medical 1 SdL?gal, of Insane Patient. 



20 



Lea Brothers & Co.'s Publications — Surgery. 



C. L. Oxon., LL. JD. 



GROSS, S. JD., 31. JD., LL. JD., JD 

Cantab., 

Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia. 
A System of Surgery : Pathological, Diagnostic, Therapeutic and Operative. 
Sixth edition, thoroughly revised and greatly improved. In two large and beautifully- 
printed imperial octavo volumes containing 2382 pages, illustrated by 1623 engravings. 
Strongly bound in leather, raised bands, $15; half Kussia, raised bands, $16. 

Dr. Gross' System of Surqery has long been the 
standard work on that subject for students and 
practitioners. — London Lancet, May 10, 1884. 

The work as a whole needs no commendation. 
Many years ago it earned for itself the enviable rep- 
utation of the leading American work on surgery, 
and it is still capable of maintaining that standard. 
The reason for this need only be mentioned to be 
appreciated. The author has always been calm 
and judicious in his statements, has based his con- 
clusions on much study and personal experience, 
has been able to grasp his subject in its entirety, 
and, above all, has conscientiously adhered to 
truth and fact, weighing the evidence, pro and 
con, accordingly. A considerable amount of new 



material has been introduced, and altogether the 
distinguished autiior has reason to be satisfied 
that he has placed the work fully abreast of the 
state of our knowledge. — Med. Record, Nov. 18, 1882. 
His System of Surgery, which, since its first edi- 
tion in 1859, has been a standard work in this 
country as well as in America, in "the whole 
domain of surgery," tells how earnest and labori- 
ous and wise a surgeon he was, how thoroughly 
he appreciated the work done by men in other 
countries, and how much he contributed to pro- 
mote the science and practice of surgery in his 
own. There has been no man to whom America 
is so much indebted in this respect as the Nestor 
of surgery. — British Medical Journal, May 10, 1884. 



ASMMUBST, JOHN, Jr., 3f. D., 

Professor of Clinical Surgery, Univ. of Penna., Surgeon to the Episcopal Hospital, Philadelphia. 

The Principles and Practice of Surgery. Fourth edition, enlarged and 
revised. In one large and handsome octavo volume of about 1100 pages, with about 575 
illustrations. Preparing. 

GOULD, A. JPFABCF, M. S., M. B., F. B. C. S„ 

Assistant Surgeon to Middlesex Hospital. 

Elements of Surgical Diagnosis. In one pocket-size 12mo. volume of 589 
pages. Cloth, $2.00. Just ready. See Students' Series of Manuals, page 3. 



The student and practitioner will find the 
principles of surgical diagnosis very satisfactorily 
set forth with all unnecessary verbiage elimi- 
nated. Every medical student attending lectures 
should have a copy to study during the intervals, 



and if practitioners would devote a portion of their 
leisure to the study of it, they would receive 
immense benefit in the way of refreshing their 
knowledge and bringing it up to the present state 
of progress. — Cincinnati Medical News, Jan., 1885. 



GLBJSJEY, V. P., 31. L>., 

Surgeon to the Orthopaedic Hospital, New York, etc. 
Orthopsedic Surgery. For the use of Practitioners and Students. In one hand- 
some octavo volume, profusely illustrated. Preparing. 



BOBFBTS, JOHJST B., A. M., M. JD., 

Lecturer on Anatomy and on Operative Surgery at the Philadelphia School of Anatomy. 

The Principles and Practice of Surgery. For the use of Students and 
Practitioners of Medicine and Surgery. In one very handsome octavo volume of about 500 
pages, with many illustrations. Preparing. 

BELLAMY, FDWABJD, F. B. C. S., 

Surgeon and Lecturer on Surgery at Charing Cross Hospital, Examiner in Anatomy Royal 
College of Surgeons, London. 
Operative Surgery. Shortly. See Students' Series of Manuals, page 3. 



STL3LSOJT, LFWLS A., B. A., M. JD., 

Prof, of Pathol. Anat. at the Univ. of the City of New York, Surgeon and Curator to Bellevue Hosp. 

A Manual of Operative Surgery. In one very handsome royal 12mo. volume 
of 477 pages, with 332 illustrations. Cloth, $2.50. 

every student should possess one. This work 



This volume is devoted entirely to operative sur- 
gery, and is intended to familiarize the student 
with the details of operations and the different 
modes of performing them. The work is hand- 
somely illustrated, and the descriptions are clear 
and well-drawn. It is a clever and useful volume; 



does away with the necessity of pondering over 
larger works on surgery for descriptions of opera- 
tions, as it presents in a nutshell what is wanted 
by the surgeon without an elaborate search to 
find it.— Maryland Medical Journal, August, 1878. 



SARGENT ON BANDAGING and OTHER OPERA- 
TIONS OF MINOR SURGERY. New edition, 
with a Chapter on military surgery. One 12mo. 
volume of 383 pages, with 187 cuts. Cloth, $1.75. 

MILLER'S PRINCIPLES OF SURGERY. Fourth 
American from the third Edinburgh edition. In 
one 8vo. vol. of 038 pages, with 340 illustrations. 
Cloth, $3.75. 

MILLER'S PRACTICE OF SURGERY. Fourth 
and revised American from the last Edinburgh 
edition. In one large 8vo. vol. of 682 pages, with 
364 illustrations. Cloth, $3.75. 



PIRRIE'S PRINCIPLES AND PRACTICE OF 

SURGERY. Edited by John Neill, M. D. In 

one 8vo. vol. of 784 pp. with 316 illus. Cloth, $3.75. 
COOPER'S LECTURES ON THE PRINCIPLES 

AND PRACTICE OF SURGERY. In one 8vo.vol. 

of 767 pages. Cloth, $2.00. 
SKEY'S OPERATIVE SURGERY. In one vol. 8vo- 

of 661 pages, with 81 woodcuts. Cloth, $3.25. 
GIBSON'S INSTITUTES AND PRACTICE OF 

SURGERY. Eighth edition. In two octavo vols. 

of 965 pages, with 34 plates. Leather $6.50. 



Lea Brothers & Co.'s Publications — Surgery. 



21 



ERICHSEX, JOHX E., F. R. S., F. R. C. S., 

Professor of Surgery in University College, London, etc. 

The Science and Art of Surgery; Being ■ Treatii pcml Enjorii 

eases and Operations. From the eighth and enlarged English edition. In t* 

beautiful octavo volumes of 2 :ed with 

Cloth, 89; leather, raised bands, $11 ; half Ru 
After the profession has placed it* approval upon mu*h to be said in nt or criti- 



awork to the extent of purchasing seven editions, 

it does not need to be introduced. Simultaneous 
with the appearance of this edition a translation 
is being made into Italian and Spanish. Thus 
this favorite text-book on surgery holds its own in 
spite of numerous rivals at the end of thirty 
It is a grand book, worthy of the art in the interest 
of which it is written. — Detroit Lancet, Jan. I 



cism. That it still 

be author infuses into it 
.■id ripe judg 
committed to no i 

lings are the ruli: . 
: 



- -• 

After being before the profession for thii- 
years and maintaining during that period a re- 
putation as a leading work on surgery, there is not 

BRYAXT, THOMAS, F. R. ( . S.. 

Surgeon and Lecturer on Surgery a! • al, London. 

The Practice of Surgery. Fourth American from the fourth i Eng- 

lish edition. In one large and very handsome imperial octavo volunu 
727 illustrations. Cloth, $6.50; leather, $7.50; half J 

The treatise takes in the whole field of surgery, nagnifieent work upon - 

that of the eye, the ear, the female orgai - lition in this country. -' 

psedi s, venereal diseases, and military surgery, the high appreciation in which it i* held • 



as well as more common and general to] . 
of these are treated with clearness and with 
sufficient fulness to suit all practical purposes. 
The illustrations are numerous and well printed. 
We do not doubt that this new edition will con- 
tinue to maintain the popularity of this standard 
work. — Medici/ and Surgical Reporter, Fe'o 



American profession. [1 

the author. That it la the v. 
on surgery f<>r 

there ran be do doubt The author H 
understood just m hat a stud- 
prepared the work 
t 



By the same Author. 
Diseases of the Breast. In one 12mo. volume. /' 

•Is, page 3. 

ESM ARCII, L»\ FRIED 11 1 < II. 

Professor of Surgery at t : 

Early Aid in Injuries and Accidents. Five Ambnl 
lated by Ff. K. H. Princes Christian, [none handsome small L2mavoli 
pages, with 24 illustrations. Cloth, 75 cents. 

The course of instruction is divided Into I 
sections or lectures. The first, or introductory 
lecture, gives a brief account of the structure and 
organization of the human body, Uluntrated by 
clear, suitable diagrams. The second tea 
to give judicious help in ordinary injuries — contu- h 



■ it.-, <>f dr. • 
and the fifth lecture 






sions, wounds, hemorrhage and poisoned wounds 

The third treats of first aid in cases of fracture 
and of dislocations, in sprains and in burn-. Next, 

TREVES, FREDERICK, /. /.\ C. v. 

Assistant Surgeon to 

Intestinal Obstruction, born ges,_with 60 

illustrations. Limp cloth, bl 
page 3. 

A standard work on asubj.- 
so comprehensively treated by any c >n temporary 
English writer. Its completeness rend< 
review difficult, since every cl 
nute attention, and it le Impossible to do tl 



. 






BALL, CHARLES />'.♦ M. Ch. % l>«t>., I . B. < : & /:.. 

Diseases of the Rectum and Anus. In 
Preparing. Sec 

BTJTLIJST, HENRY /.. /. /.'. C. v. 

Diseases of the Tongu ^ Smim qf Ghmeal 

Manuals, page 3. 

DRUITT, ROBERT, M. R. C. 8., etc. 

The Principles and Practice of M< 
London edition. In one Bvo. ?olum< l,, »- 



• 



22 Lea Brothers & Co.'s Publications — Surgery. 

HOLMES, TIMOTHY, M. A., 

Surgeon and Lecturer on Surgery at St. George's Hospital, London. 

A System of Surgery ; Theoretical and Practical. IN TEEATISES BY 
VARIOUS AUTHORS. American edition, thoroughly revised and re-edited 
by John H. Packard, M. D., Surgeon to the Episcopal and St. Joseph's Hospitals, 
Philadelphia, assisted by a corps of thirty-three of the most eminent American surgeons. 
In three large and very handsome imperial octavo volumes containing 3137 double- 
columned pages, with 979 illustrations on wood and 13 lithographic plates, beautifully 
colored. Price per volume, cloth, $6.00 ; leather, $7.00 ; half Russia, $7.50. Per set, cloth, 
$18.00 ; leather, $21.00 ; half Russia, $22.50. Sold only by subscription. 

Volume I. contains General Pathology, Morbid Processes, Injuries in Gen- 
eral, Complications of Injuries and Injuries of Regions. 

Volume II. contains Diseases of Organs of Special Sense, Circulatory Sys- 
tem, Digestive Tract and Genito-Urinary Organs. 

Volume III. contains Diseases of the Respiratory Organs, Bones, Joints and 
Muscles, Diseases of the Nervous System, Gunshot Wounds, Operative and 
Minor Surgery, and Miscellaneous Subjects (including an essay on Hospitals). 

This great work, issued some years since in England, has won such universal confi- 
dence wherever the language is spoken that its republication here, in a form more 
thoroughly adapted to the wants of the American practitioner, has seemed to be a duty 
owing to the profession. To accomplish this, each article has been placed in the hands of 
a gentleman specially competent to treat its subject, and no labor has been spared to bring 
each one up to the foremost level of the times, and to adapt it thoroughly to the practice 
of the country. In certain cases this has rendered necessary the substitution of an entirely 
new essay for the original, as in the case of the articles on Skin Diseases, on Diseases of 
the Absorbent System, and on Anaesthetics, in the use of which American practice differs 
from that of England. The same careful and conscientious revision has been pursued 
throughout, leading to an increase of nearly one-fourth in matter, while the series of 
illustrations has been nearly trebled, and the whole is presented as a complete exponent 
of British and American Surgery, adapted to the daily needs of the working practitioner. 

In order to bring it within the reach of every member of the profession, the five vol- 
umes of the original have been compressed into three by employing a double-columned 
royal octavo page, and in this improved form it is offered at less than one-half the price of the 
original. It is printed and bound to match in every detail with Reynolds' System of Medi- 
cine. The work will be sold by subscription only, and in due time every member of the 
profession will be called upon and offered an opportunity to subscribe. 



The authors of the original English edition are 
men of the frout rank in England, and Dr. Packard 
has been fortunate in securing as his American 
coadjutors such men as Bartholow, Hyde, Hunt, 
Conner, Stimson, Morton, Hodgen, Jewell and 
their colleagues. As a whole, the work will be 
solid and substantial, and a valuable addition to 



the library of any medical man. It is more wieldly 
and more useful than the English edition, and with. 
its companion work — "Reynolds' System of Medi- 
cine" — will well represent the present state of our 
science. One who is familiar with those two works 
will be fairly well furnished head-wise and hand- 
wise. — The Medical News, Jan. 7, 1882. 



STIMSON, LEWIS A., B. A., M. D. 9 

Professor of Pathological Anatomy at the University of the City of New York, Surgeon and Curator 
to J&ellevue Hospital, Surgeon to the Presbyterian Hospital, New York, etc. 

A Practical Treatise on Fractures. In one very handsome octavo volume of 
598 pages, with 360 beautiful illustrations. Cloth, $4.75 ; leather, $5.75. 

the surgeon in full practice. — N. O. Medical and 



The author has given to the medical profession 
in this treatise on fractures what is likely to be- 
come a standard work on the subject. It is certainly 
not surpassed by any work written in the English, 
or, for that matter, any other language. The au- 
thor tells us in a short, concise and comprehensive 
manner, all that is known about his subject. There 
is nothing scanty or superficial about it, as in most 
other treatises ; "on the contrary, everything is thor- 
ough. The chapters on repair of fractures and their 
treatment show him not only to be a profound stu- 
dent, but likewise a practical surgeon and patholo- 
gist. His mode of treatment of the different fract- 
ures is eminently sound and practical. We consider 
this work one of the best on fractures ; and it will 
be welcomed not only as a text-book, but also by 



Surgical Journal, March, 1883. 

The author gives in clear language all that the 
practical surgeon need know of the science of 
tractures, their etiology, symptoms, processes of 
union, and treatment, according to the latest de- 
velopments. On the basis of mechanical analysis 
the author accurately and clearly explains the 
clinical features of fractures, and by the same 
method arrives at the proper diagnosis snd rational 
treatment. A thorough explanation of the patho- 
logical anatomy and a careful description of the 
various methods of procedure make the book full 
of value for every practitioner. — Centralblatt fur 
Chirurgie, May 19, 1883. 



3IAHSM, MOWAMD, F. M. C. 8., 

Senior Assistant Surgeon to and Lecturer on Anatomy at St. Bartholomew) 1 's Hospital, London. 
Diseases of the Joints. In one 12mo. volume. Preparing. See Series of Clinical 
Manuals, page 3. 

PICK, T. EICKEMING, E. B. C. S., 

Surgeon to and Lecturer on Surgery at St. Georges Hospital, London. 

Fractures and Dislocations. In one 12mo. volume. Preparing. See Series 
of Clinical Manuals, page 3. 



Lea Brothers & Co.'s Publications — Frac., Disloc, Ophthal. 



HAMILTON, FRANK H., M. 1)., LL. 2>., 

Surgeon to Bellevue Hospital, Sew York. 

A Practical Treatise on Fractures and Dislocations. Seventh,.; 
thoroughly revised and much improved. In one very !, 

pages, with 379 illustrations. Cloth, $5.50; leather, $6.50; v me half B 
open back, §7.00. Just ready. 

Hamilton's great experience and wide acquaint- other language.— M 

ance with the literature of the subject have enabled With 

him to complete the labors of Malgaigne and to rank among the i 

place the rea«ler in possession of the advances and ha- 

made during thirty years. The editions have fol- world over as an authority i: 

lowed each other rapidly, and they introduce us which it tre^- 

to the methods of practice, often so wise, of his found u 

American colleagues. More practical than Mai- find it scientific, forcible 

gaignes work, it will serve as a valuable guide to exhaustive in detail, and 

the practitioner in the numerous and embarrass- of wise conaervatisE 

ing cases which come under his observation. — Jan. 10, I 

Archives Genera es . Pari-, Nov. For a quarter of a century the author ha- 

There is no longer any necessity for review;: that it 

this admirable work. It has triumphantly a kind in ar 

vanced to its seventh edition, its venerable a text-book and 

talented author still keeps abreast of the times, and guidance for pra uvhIu- 

and it is still the most exhaustive practical trea- able*— A Mddieal and Surgical" J<. 
tise on fractures and dislocations in this or a 



JTJLER, JLENRY E. 9 F. B. C. &, 

Senior Ass't Surgeon, Ronil Westminster Ophika ' ite C'inica elds, London. 

A Handbook of Ophthalmic Science and Practice. In ope ban 
octavo volume of 460 pages, with 125 wood tiuns from the 

Test-types of Jaeger and Snellen. Cloth, $4.50 ; leather, J dy. 

This work is distinguished by the great num- and typical illust. . ill important eve 

ber of colored plates which appear in it for ill iced in j 

trating various pathological conditions. They i 
very beautiful in appearance, and have been best ill 
executed with great care as to accuracy. An ex- which 
amination of the work shows it to be one of high better, these illust: 
standing, one that will be regarded as an author: 
among ophthalmologist?. The treatment 
mended is such as the author ha* learned from vi< 
actual experience to be the best. — Cincmi 
•-, Dec. 1884. 

It presents to the student concise description.-. Lancet, Juxl l 



WELLS, J. SOJEZBEItG, F. R. C. &, 

Professor of Ophthalmology in . 
A Treatise on Diseases of the Eye. Fourl an from the third Lond □ 

edition. Thoroughly revised, with copious additions, by Chaju 
and Pathologist to the New xoi I Ear Infirmary. In one 1 

822 pages, with 257 illustration aix colore 

types ol and Snellen. Cloth. 

The present edition appearf 
years since the publication of the last An 
edition, and vet, from the numei 
tigation.- thai have been made in thin branch of • 
■ 

required to meet I 
upon this subject. A critical examtnati 

NETTLES HIP, EI>\\Ai:i>. 1 . /«'. C. 8., 

Oph 
The Student's Guide to Di "• W' 1 ! 1 ' 

teronthe Detection of Color-Blindness, by William 
to the Jel; 
illustrations. 52.00. 

Th 
favor i 

teral i 
out the imprint of sound Judgi 
vast experience. The illust 

BROWNE, EIHIAU A.. 

Surgeon to I I 

How to Use the C 
thalmoscopy, arranged for " ll ° 

pages, with 35 ill : -" - ____ 

,„„.n.T-. -.• -u.\ -I lion. In on. -i»Tn rob 



Phis admirable guide bids (air I 
oritetexibookonophthal. 

. practiti 






LAWSON OX INJURIES TO THE EYE, i 
AND EYELIDS: Their [mn 
Effect 104 pp-, •»- IHus. CI 

LAURENCE \\l> MOON'S HANI 
OPHTHALMIC TsURQERY.for I 



AND EYELIDS 

Effect* 8 VO.. lot pp.,92 IHus. Cloth, I 



24 Lea Brothers & Co.'s Publications — OtoL, Dent.,TJrin. Dis. 
BUBNFTT, CSABLF8 II., A. M., M. &., 

Professor of Otology in the Philadelphia Polyclinic; President of the American Otological Society. 

The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise 
for the use of Medical Students and Practitioners. New (second) edition. In one handsome 
octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00 ; leather, $5.00. Just ready. 



We note with pleasure the appearance of a second 
edition of this valuable work. When it first came 
out it was accepted by the profession as one of 
the standard works on modern aural surgery in 
the English language; and in his second edition 
Dr. Burnett has fully maintained his reputation, 
for the book is replete with valuable information 
and suggestions. The revision has been carefully 



carried out, and much new matter added. Dr. 
Burnett's work must be regarded as a very valua- 
ble contribution to aural surgery, not only on 
account of its comprehensiveness, but because it 
contains the results of the careful personal observa- 
tion and experience of this eminent aural surgeon. 
— London Lancet, Feb. 21, 1885. 



FOLITZEB, ADAM, 

Imperial- Royal Prof, of Aural Therap. in the Univ. of Vienna. 

A Text-Book of the Ear and its Diseases. Translated, at the Author's re- 
quest, by James Patterson Casseees, M. D., M. R. C. S. In one handsome octavo vol- 
ume of 800 pages, with 257 original illustrations. Cloth, $5.50. 

The work itself we do not hesitate to pronounce 
the best upon the subject of aural diseases which 
has ever appeared, systematic without being too 
diffuse on obsolete subjects, and eminently prac- 
tical in every sense. The anatomical descriptions 
of each separate division of the ear are admirable, 
and profusely illustrated by woodcuts. They are 
followed immediately by the physiology of the 



section, and this again by the pathological physi- 
ology, an arrangement which serves to keep up the 
interest of the student by showing the direct ap- 
plication of what has preceded to the study of dis- 
ease. The whole work can be recommended as a 
reliable guide to the student, and an efficient aid 
to the practitioner in his treatment. — Boston Med- 
ical and Surgical Journal, June 7, 1883. 



COLFMAN, A., L. M. C. P., F. B. C. 8., Exam. L. D. 8., 

Senior Dent. Surg, and Led. on Dent. Surg, at St. Bartholomew's LTosp. and the Dent. Hosp., London. 

A Manual of Dental Surgery and Pathology. Thoroughly revised and 
adapted to the use of American Students, by Thomas C. Stelewagen, M. A., M. D., 
D. I). S., Prof, of Physiology at the Philadelphia Dental College. In one handsome octavo 
volume of 412 pages, with 331 illustrations. Cloth, $3.25. 



This volume deserves to rank among the most 
important of recent contributions to dental litera- 
ture. Mr. Coleman has presented his methods of 
practice, for the most part, in a plain and concise 
manner, and the work of the American editor has 
been conscientiously performed. He has evidently 
labored to present his convictions of the best modes 



of practice for the instruction of those commenc- 
ing a professional career, and he has faithfully en- 
deavored to teach to others all that he has acquired 
by his own observation and experience. The book 
deserves a place in the library of every dentist. 
— Dental Cosmos, May, 1882. 



GBO88, 8. !>., M. JD., LL. !>., D. C. L., etc. 

A Practical Treatise on the Diseases, Injuries and Malformations 
of the Urinary Bladder, the Prostate Gland and the Urethra. Third 
edition, thoroughly revised by Samuel W. Gross, M. D., Professor of the Principles of 
Surgery and of Clinical Surgery in the Jefferson Medical College, Philadelphia. In one 
octavo volume of 574 pages, with 170 illustrations. Cloth, $4.50. 

BOBFBT8, WILLIAM, M. JD., 

Lecturer on Medicine m the Manchester School of Medicine, etc. 

A Practical Treatise on Urinary and Renal Diseases, including Uri- 
nary Deposits. Fourth American from the fourth London edition. In one large 
and handsome octavo volume. Illustrated by numerous engravings. Shortly. 

MOBBI8, JBEFNBY, M. B., F. B. C. 8., 

Surgeon to and Lecturer on Surgery at Middlesex Hospital, London. 

Surgical Diseases of the Kidney. In one 12mo. volume. Preparing. See 
Series of Clinical Manuals, page 3. 

LUCA8, CLFMFJSTJl\m7b7,B. 8., F. B. C. 8., 

Senior Assistant Surgeon to Guy's Hospital, London. 
Diseases of the Urethra. In one 12mo. volume. Preparing. See Series 
■of Clinical Manuals, page 3. 

THOMPSON, 8IB MFNBtT 

Surgeon and Professor of Clinical Surgery to University College Hospital, London. 

Lectures on Diseases of the Urinary Organs. Second American from the 
third English edition. In one 8vo. volume of 203 pp., with 25 illustrations. Cloth, $2.25. 

By the Same Author. 
On the Pathology and Treatment of Stricture of the Urethra and 
Urinary Fistulse. From the third English edition. In one octavo volume of 359 
pages, with 47 cuts and 3 plates. Cloth, $3.50. 

BASHAM ON RENAL DISEASES : A Clinical I one 12mo. vol. of 304 pages, with 21 illustrations. 
Guide to their Diagnosis and Treatment. In | Cloth, $2.00. 



Lea Brothers & Co.'s Publications — Venereal, Impotence. 



25 



BTJMSTFAD, F. J., 

31. n., LL. n., 

Late Professor of Venereal Diseases 
at the College of Physicians and 

Surgeons, New York, etc. 



and TAYLOR, R. W., 

A. M., M. D., 

Surgeon to Charity Hospital, New York, Prof, of 
Venereal and Skin Diseases m the University of 
Vermont, Pres. of the Am. Dtrmatological Ann. 



The Pathology and Treatment of Venereal Diseases. Including the 

results of recent investigations upon the subject. Fifth edition, revised and largely re- 
written, by Dr. Taylor. In one large and handsome octavo volume of with 
139 illustrations, and thirteen chromo-lithographic figures. Cloth, $4.75; leather, $5.75; 
very handsome half Russia, $6.25. 



It is a splendid record of honest labor, wide 
research, just comparison, careful scrutiny and 
original experience, which will always be held as 
a high credit to American medical literature. This 
is not only the best work in the English language 
upon the subjects of which it treats, but also one 
which has no equal in other tongues for its clear, 
comprehensive and practical handling of its 
themes. — American Journal of the Medical Sciences, 
Jan, 1884. 

It is certainly the best single treatise on vene- 
real in our own, and probably the best in any lan- 
guage. — Boston Medical and Surgical Journal, April 
3,1884. 



The character of this standard work is so well 
known that it would be superfluous here to pass in 
review its general or special points of excellence. 
The verdict of the profession has been passed; it 
has been accepted as the most thorough and com- 
plete exposition of the pathology and treatment of 
venereal diseases in the language. Admirable as a 
model of clear description, an exponent of sound 
pathological doctrine, and a guide for rational and 
successful treatment, it is an ornament to the medi- 
cal literature of this country. The additions made 
to the present edition are eminently judicious, 
from the standpoint of practical utility.— Journal oj 
Cutaneous and Venereal Diseases, Jan. 1884. 



HUTCHINSON, JONATHAN, F. R. S., F. R. C. S., 

Consulting Surgeon to the London Hospital. 
Syphilis. In one 12mo. volume. Preparing. See Series of Clinical Manuals, page 3. 



CORJSLL, V., 

Professor to the Faculty of Medicine of Paris, and Physician to the Lourcine Hospital. 

Syphilis, its Morbid Anatomy, Diagnosis and Treatment. Specially 
revised by the Author, and translated with notes and additions by J. Hknry ('. Simes, 
M. D., Demonstrator of Pathological Histology in the University of Pennsylvania, and 
J. William White, M. D., Lecturer on Venereal Diseases and Demonstrator of Surgery 
in the University of Pennsylvania. In one handsome octavo volume of 401 pages, with 
84 very beautiful illustrations. Cloth, $3.75. 

the whole volume is the clinical experience of the 
author or the wide acquaintance of the translators 
with medical literature more evident. The anat- 
omy, the histology, the pathology and the clinical 
features of syphilis are represented la this work in 
their best, most practical and most instructive 
form, and no one will rise from its perusal without 
the feeling that his grasp of the wide and Impor- 
tant -abject on which it treats is a stronger and 
surer one. — The London Practitioner, Jan. I 



The anatomical and histological characters of the 
hard and soft sore are admirably described. The 
multiform cutaneous manifestations of the disease 
are dealt with histologically in a masterly way, as 
we should indeed expect them to be, and the 
accompanying illustrations are executed carefully 
and well. The various nervous lesions which are 
the recognized outcome of the syphilitic dyscrasia 
are treated with care and consideration. Syphilitic 
epilepsy, paralysis, cerebral syphilis and locomotor 
ataxia are subjects full of interest; and nowhere in 



GROSS, SAMUEL W., A. 31., 31. JD., 

Pre>fessor of the Principles of Surgery and of Clinical Surgery in the Jefferson Medical ( 

A Practical Treatise on Impotence, Sterility, and Allied Disorders 
of the Male Sexual Organs. Second edition, thoroughly revised. In one very hand- 
some octavo volume of 168 pages, with 16 illustrations. Cloth, $1.60. 

The author of this monograph Is a man of posi- Thia work will d.-riv.- rains from the high 
tive convictions and vigorous style. Thisisfusti- tag of ill author, aside from the fact of it* i 
fied by In- experience and hy hi- study, which hae so rapidly Into lu second edition. This Is, indeed, 

hand in hand with hi- experience. In regard 
to the various organic and functional disoi 
the male generative apparatus, he has had ex- 
ceptional opportunities for ol and his 
book shows that he elected to compare 

his own views with those of other authors. The 

result is a work which can be safely recommended 
to both physicians and surgeons as a guide in the 
treatment of the disturbances II refers to It I 

, the Bublecl with which we are 
acquainted.— 77k -, Bept i, U 



BO rapt 

a DOCK that 

in his librai y 



very physician will be i*':a<i U 

to !„•' read w ith profll to him 



i with profit to i 
and with Incalculable benefit I nt. Be- 

i .-.i in the title, n hich are 
treated of In their various formn and d> 
spermatorrhoea and prostatorrhoea are al 
considered. The work is thorough Ij 
character, and will be especially iisvful to the 
. practitlont 



CULLER I /:/;. A., A BUMSTEA IK F. ,/.. )/./>.. /./,./>.. 

Surgeon to th> // 

York. 

An Atlas of Venereal Diseases. I n lated and edited by I '■ Bi m- 

steat), M. I). In our imperial it<>. volume of 328 pag< -. double-columns, will 
containing about 150 figures, beautifully colored, many of them the -i/<- ol lift 
bound in cloth. $17.00. A specimen of the plates and text sent by mail, on n . eipl ol 

HILL ON 8YPHILI8 AND LOCAL I ON rAGIOl 

DISORDERS. In one 8vo vol. of 479 p. Cloth,t3.26. PRINCIPALLY THE ORGAN* 
LEE'S LECTURES ON BYPHILIfi Inonesvo 



26 



Lea Brothers & Co.'s Publications — Diseases of Skin. 



JETYUE, J. KEVINS, A. 31., M. D., 

Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. 

A Practical Treatise on Diseases of the Skin. For the use of Students and 
Practitioners. In one handsome octavo volume of 570 pages, with 66 beautiful and elab- 
orate illustrations. Cloth, $4.25 ; leather, $5.25. 



practi- 
ants of 



The author has given the student and 
tioner a work admirably adapted to the ^ 
each. We can heartily commend the book as a 
valuable addition to our literature and a reliable 
guide to students and practitioners in their studies 
and practice. — Am. Journ. of Med. ScL, July, 1883. 

Especially to be praised are the practical sug- 
gestions as to what may be called the common- 
sense treatment of eczema. It is quite impossible 
to exaggerate the judiciousness with which the 
formulae for the external treatment of eczema are 
selected, and what is of equal importance, the full 
and clear instructions for their use. — London Medi- 
cal Times and Gazette, July 28, 1883. 

The work of Dr. Hyde will be awarded a high 
position. The student of medicine will find' it 
peculiarly adapted to his wants. Notwithstanding 
the extent of the subject to which it is devoted, 
yet it is limited to a single and not very large vol- 
ume, without omitting a proper discussion of the 
topics. The conciseness of the volume, and the 
setting forth of only what can be held as facts will 
also make it acceptable to general practitioners. 
— Cincinnati Medical News, Feb. 1883. 

The aim of the author has been to present to his 
readers a work not only expounding the most 
modern conceptions of his subject, but presenting 
what is of standard value. He has more especially 
devoted its pages to the treatment of disease, and 
by his detailed descriptions of therapeutic meas- 
ures has adapted them to the needs of the physi- 



cian in active practice. In dealing with these 
questions the author leaves nothing to the pre- 
sumed knowledge of the reader, but enters thor- 
oughly into the most minute description, so that 
one is not only told what should be done under 
given conditions but how to do it as well. It is 
therefore in the best sense "a practical treatise." 
That it is comprehensive, a glance at the index 
will show. — Maryland Medical Journal, July 7, 1883, 
Professor Hyde has long been known as one of 
the most intelligent and enthusiastic representa- 
tives of dermatology in the west. His numerous 
contributions to the literature of this specialty 
have gained for him a favorable recognition as a 
careful, conscientious and original observer. The 
remarkable advances made in our knowledge of 
diseases of the skin, especially from the stand- 
point of pathological histology and improved 
methods of treatment, necessitate a revision of 
the older text-books at short intervals in order to 
bring them up to the standard demanded by the 
march of science. This last contribution of Dr. 
Hyde is an effort in this direction. He has at- 
tempted, as he informs us, the task of presenting 
in a condensed form the results of the latest ob- 
servation and experience. A careful examination 
of the work convinces us that he has accomplished 
his task with painstaking fidelity and with a cred- 
itable result. — Journal of Cutaneous and Venereal 
Diseases, June, 1883. 



FOX, T., 3I.L., F.B. C. JP., and FOX, T. C, B.A., 3I.B. C.S., 

Physician to the Department for Skin Diseases, Physician for Diseases of the Skin to the 

University College Hospital, London. Westminster Hospital, London. 

An Epitome of Skin Diseases. "With Formulae. For Students and Prac- 
titioners. Third edition, revised and enlarged. In one very handsome 12mo. volume 
of 238 pages. Cloth, $1.25. 



The third edition of this convenient handbook 
calls for notice owing to the revision and expansion 
which it has undergone. The arrangement of skin 
diseases in alphabetical order, which is the method 
of classification adopted in this work, becomes a 
positive advantage to the student. The book is 
one which we can strongly recommend, not only 
to students but also to practitioners who require a 
compendious summary of the present state of 
dermatology. — British Medical Journal, July 2, 1883. 

We cordially recommend Fox's Epitome to those 
whose time is limited and who wish a handy 



manual to lie upon the table for instant reference, 
its alphabetical arrangement is suited to this use, 
for all one has to know is the name of the disease, 
and here are its description and the appropriate 
treatment at hand and ready for instant applica- 
tion. The present edition has been very carefully 
revised and a number of new diseases are de- 
scribed, while most of the recent additions to 
dermal therapeutics find mention, and the formu- 
lary at the end of the book has been considerably 
augmented. — The Medical News, December, 1883. 



MOMMIS, MALCOLM, M. D., 

Joint Lecturer on Dermatology at St. Mary's Hospital Medical School, London. 
Skin Diseases ; Including their Definitions, Symptoms, Diagnosis, Prognosis, Mor- 
bid Anatomy and Treatment. A Manual for Students and Practitioners. In one 12mo. 
volume of 316 pages, with illustrations. Cloth, $1.75. 

for clearness of expression and methodical ar- 



To physicians who would like to know something 
about skin diseases, so that when a patient pre- 
sents himself for relief they can make a correct 
diagnosis and prescribe a rational treatment, we 
unhesitatingly recommend this little book of Dr. 
Morris. The affections of the skin are described 
in a terse, lucid manner, and their several charac- 
teristics so plainly set forth that diagnosis will be 
easy. The treatment in each case is such as the 
experience of the most eminent dermatologists ad- 
vises. — Cincinnati Medical Neivs, April, 18S0. 

This is emphatically a learner's book; for we 
can safely say, that in the whole range of medical 
literature there is no book of a like scope which 



rangement is better adapted to promote a rational 
conception of dermatology — a branch confessedly 
difficult and perplexing to the beginner. — St. Louis 
Courier of Medicine, April, 1880. 

The writer has certainly given in a small compass 
a large amount of well-compiled information, and 
his little book compares favorably with any other 
which has emanated from England, while in many 
points he has emancipated himself from the stub- 
bornly adhered to errors of others of his country- 
men. There is certainly excellent material in the 
book which will well repay perusal. — Boston Med. 
and Surg. Journ., March, 1880. 



WILSON, ERASMUS, F. It. S. 

The Student's Book of Cutaneous Medicine and Diseases of the Skin. 

In one handsome small octavo volume of 535 pages. Cloth, $3.50. 

UILLIEB, THOMAS, M. D., 

Physician to the Skin Department of University College, London. 
Handbook of Skin Diseases ; for Students and Practitioners. Second Ameri- 
can edition. In one 12mo. volume of 353 pages, with plates. Cloth, $2.25. 



Lea Brothers & Co.'s Publications — Dis. of Women. 27 

AJST AMERICAN SYSTEM OF GYNJSCOLOG Y. 

A System of Gynaecology, in Treatises by Various Autko 
by Matthew D. Manx, M. D., Professor of 

versity of Buffalo. N. Y. In two handsome octavo volumes, richly illusti 
preparation. 

LIST OF CONTRIBUTORS. 

FORDYCE BARKER, M. D., CHARLES CARS BC. I\, 

ROBERT BATTEV, M. D., WILLIAM T. L 

SAMUEL C. BUSEY, M. L, MATTHEW D. MANN, M. I'.. 
HENRY F. CAMPBELL, M. D., 1RT B. MAURY, M. I'., 

BENJAMIN F. DAWSON, M. D., PALMER, M. !>.. 

WILLIAM GOODELL, M. D., WILLIAM M. POLK, M. P., 
HENRY F. GARRIGUES, M. D., LDDEUS A. RE AMY, M. I'., 

SAMUEL W. GROSS, M. I.)., A. I'. ROCKWELL, M. 1'.. 

JAMES B. HUNTER, M. D., ALBERT II. SMITH. M. I>., 
WILLIAM T. HOWARD, M. D., K. I' 

A. REEVES JACKSON, M. D., T. GAILLARD THOMAS, M. I v. 
EDWARD W. JENKS, M. D., Ill', M. I'., 

WILLIAM II. WELCH, M. D. 



THOZIAS, T. GAILLAHI), 31. D. 9 

Professor of Diseases of Women in th Physicians and Surgeon*, N. Y. 

A Practical Treatise on the Diseases of Women. F 
revised and rewritten. In one large am! hands • volume < : 

illustrations. Cloth, |5.00 ; leather, $6.00 ; very handsome half Russia, raised bands, | 

The words which follow "fifth edition" are in vious <> 
this case no mere formal announcement. T: uer it Is unequal !< Kll any 

alterations and additions which have been i S rgieal Journal. A j > r i 1 7, 1880. 

both numerous and important. The attraction It has been enlarged and carefully revised. It Is 
and the permanent character of this book lie in a <• 

the clearness and truth of the clinical description rtyle of arm mterly 

of diseases; the fertility of the author in thera- manner in which each pi 
peutic resources and the fulness with which the honest convictions derii 
details of treatment are described; the definite largest elinica 

character of the teaching; and last, but not least in this country, all "I 'l In the 

the evident candor whion pervades it We would highest terms to th< 
also particularize the fulness with which t I , Jan. 1881. 

tory of the subject is gone Into, which makes the ' That the previous editl 

book additionally interesting and gives il value thought worthy n Into 

a work of reference.—/. . . . 

Gazette, July 30, 1881. Ine merit. At hoi 

The determination of the author to keep his has made it- w 
book foremost in the rank of works on gyneecology rician and gyn 
is most gratifying. Recognizing the fad that this No small cumber of additions I 
can onlv be accomplished by frequent and thor- tl 

ough revision, he has spared no pains to make the cent Improvements In treatment.— J 
present edition more desirable even than the pre- 

JEJDIS, AHTIIVH Jr., M. />., LoikL. I\ B.C. P., M". R.C. 8., 

Assist. Obstetric Physician to M 

The Diseases of Women, [ncluding their I 
Diagnosis and Treatment. A Manual for Students and Practitioners, Ii 
octavo volume of 576 pages, with 1 I- illustrations. Cloth, $3.00; leatl 

It is a pi 
good as tli i- pedal qua! 

conspi< thoroughness In 

whole ground, clearnee 

tatement. Anoth< 
the hook Is thi att< ntio 
manv minor surgical O] 
as, for instance, the use of te 
. and use of hot water 
:. nong the more common i 
ment, and yel very litl Uut them 

manv of the fcext-1 






general practitioners, who n- • 

plete rtswnii. of the whol ■ "«"• rramwmm; 

will find rtl] hints in 

I 

BARNES, ROBERT, M. Ik. /. /,'. C. P., 

ion to St. 7 
A Clinical Exposition of the 3VT ■ 
In one handsome octavo volume, with nui 

WEST, CHARLES, H/L IK 

Lectures on the Diseases of Won I 
don edition. In one octavo vol 

OHUBCHTLL ON THE RAL FEV1 

AND OTHER DISJ VB1 - PECUL1 M * TO ' 

MEN. In one 8vo. vol. of 4(14 pages. Cloth,! ,o oi >hj pa§«*. wgw,^w* 



28 Lea Brothers & Co.'s Publications — I>is. of Women, Midwf y. 
EMMET, THOMAS ADDIS, M. D., II. D., 

Surgeon to the Woman's Hospital, New York, etc. 

The Principles and Practice of Gynaecology ; For the use of Students and 
Practitioners of Medicine. New (third) edition, thoroughly revised. In one large and very- 
handsome octavo volume of 880 pages, with 150 illustrations. Cloth, $5 ; leather, $6. 
(Just ready.) 

Excerpt from the Author's Preface to the Second Edition. 

So great have been the advance and change of views during the past four years in 
Gynaecology, that the preparation of this edition has necessitated almost as much labor as 
to have rewritten the volume. Every portion has been thoroughly revised, a great deal 
has been left out, and much new matter added. 

The chapters on the relation of education and social condition to development, those 
on pelvic cellulitis, the diseases of the ovary and on ovariotomy, together with that on 
stone in the bladder, have been nearly rewritten. 

The chapters on prolapse of the vaginal walls and lacerations of the vaginal outlet, 
the methods of partial and complete removal of the uterus for malignant disease, the 
surgical treatment of fibrous tumors, diseases of the Fallopian tubes, and the diseases of 
the urethra, are essentially new, with the views and experience of the author in a form 
which has not been presented to the profession before. To these chapters not less than 
one hundred and seventy-five pages of new material have been added. 



The work may now be said fairly to represent 
the present position of gynaecology in America, 
and is one of the best, if not the best, in the Eng- 
lish language. It remains a worthy exponent of 
a life devoted to the study and practice of gynse 
cology ; a book that will be of immense value to 
the profession at large, and one which will be a 
stimulus to better work wherever it is read. — 
Boston Medical and Surgical. Journal, Jan. 29, 1885. 

Any work on gynaecology by Emmet must 
always have especial interest and value. He has 
for many years been an exceedingly busy prac- 
titioner in this department. Few men have had 
his experience and opportunities. As a guide 
either for the general practitioner or specialist, 



it is second to none other. No one can read 
Emmet without pleasure, instruction and profit. 
— Cincinnati Lancet and Clinic, Jan 31, 1885. 

It is with a feeling of pleasure that we welcome 
a work on diseases of women from so eminent a 
gynaecologist as Dr. Emmet. The work is essenti- 
ally clinical, and leaves a strong impress of the 
author's individuality. To criticize the work 
throughout with the care it merits, would demand 
far more space than is at our command. In part- 
ing, we can say that tne work teems with original 
ideas, fresh and valuable methods of practice, and 
is written in a clear and elegant style, worthy of 
the literary reputation of Longfellow and O. W. 
Holmes. — The Southern Practitioner , Feb. 1885. 



DVNCAN, J. MATTHEWS, M.D., II. D., F. H. S. E., etc. 

Clinical Lectures on the Diseases of Women ; Delivered in Saint Bar- 
tholomew's Hospital. In one handsome octavo volume of 175 pages. Cloth, $1.50. 

stamp of individuality that, if widely read, as they 



They are in every way worthy of their author ; 
indeed, we look upon them as among the most 
valuable of his contributions. They are all upon 
matters of great interest to the general practitioner. 
Some of them deal with subjects that are not, as a 
rule, adequately handled in the text-books; others 
of them, while bearing upon topics that are usually 
treated of at length in such works, yet bear such a 



certainly deserve to be, they cannot fail to exert a 
wholesome restraint upon the undue eagerness 
with which many young physicians seem bent 
upon following the wild teachings which so infest 
the gynaecology of the present day. — N. Y. Medical 
Journal, March, 1880. 



HODGE, HVGHI., M. D., 

Emeritus Professor of Obstetrics, etc., in the University of Pennsylvania. 
On Diseases Peculiar to Women; Including Displacements of the Uterus. 
Second edition, revised and enlarged. In one beautifully printed octavo volume of 519 
pages, with original illustrations. Cloth, $4.50. 

By the Same Author. 

The Principles and Practice of Obstetrics. Illustrated with large litho- 
graphic plates containing 159 figures from original photographs, and with numerous wood- 
cuts. In one large quarto volume of 542 double-columned pages. Strongly bound in 
cloth, $14.00. 

* * * Specimens of the plates and letter-press will be forwarded to any address, free by 
mail, on receipt of six cents in postage stamps. 

TAMJSriEM, S., and CHAJSTTKEUII, G. 

A Treatise on the Art of Obstetrics. Translated from the French. In 

two large octavo volumes, richly illustrated. 

HAMSBOTHAM, FRANCIS H. 9 31. D. 

The Principles and Practice of Obstetric Medicine and Surgery; 

In reference to the Process of Parturition. A new and enlarged edition, thoroughly revised 
by the Author. With additions by W. V. Keating, M. D., Professor of Obstetrics, etc., 
in the Jefferson Medical College of Philadelphia. In one large and handsome imperial 
octavo volume of 640 pages, with G4 full-page plates and 43 woodcuts in the text, contain- 
ing in all nearly 200 beautiful figures. Strongly bound in leather, with raised bands, $7. 

ASHWELIAS PRACTICAL TREATISE ON THE l American from the third and revised London 
DISEASES PECULIAR TO WOMEN. Third edition. In one 8vo. vol., pp. 520. Cloth, $3.50. 



Lea Brothers & Co.'s Publications — Rfidwifi 
PLAYFAIR, TV. S., 31. JD., F. R. C. P., 

Professor of Obstetric Medicine in King's College, London, etc, 

A Treatise on the Science and Practice of Midwifery. Thin! Ann 
edition, revised by the Author. Edited, with additions, by B ML 1». 

In one handsome octavo volume of 659 pages, with 183 illustrations. Cloth, $4; leather, 
$5 ; half Kussia, $5.50. 

The medical profession has now the opportunity all details not neees^arv for a full understanding 
of adding to their stock of standard medical works of the subject are omr. - 
one of the best volumes on midwifery ever pub- Xeics, Jan., 1880. 

lished. The subject is taken up with a master it certainly is an admirable exposition of the 
hand. The part devoted to labor in all its nuio 

presentations, the management an. I I- additions made by the Ai 

mirably arranged, and the views entertained will Harris, ■.. 
be found essentially modern, and the opii, 
pressed trustworthy. The work abounds with f 

plates, illustrating various obstetrical p value.— 7'/,. 

they are admirably wrought, and atford gr 

assistance to the student.— A. O. Medical and But- The third edition— eo soon foil 
gical Journal, March, 181 .vs that the good qualities 

If inquired of by a medical student what work re 
on obstetrics we should recommend for him, p exhausted before I 

excellence, we would undoubtedly advise him to edition, and this is 
choose Playfair's. It is of convenient size, but and rev lUthor f<>r t: 

what is of chief importance, its treatment of the which ought t 
various subjects is concise and plain. While the here being furnished with 
discussions and descriptions are sufficiently elab 
rate to render a very intelligible idea of them, yet M- 



KING, A. F. A., M. D., 

Professor of Obstetrics and 1) ien in the Medical Department of tht 

sitii, Washington, D. C, 

A Manual of Obstetrics. New edition. In <>ne very h 
of 331 pages, with 59 illustrations. ( lit! 

In a series of short paragraphs and by a con- that it will be 
densed style of composition, the v. - t to their \\ 

sented a great deal of what it is well that every c. 

obstetrician should know and be ready to pracl II t*nd 

or prescribe. The fact that the demand for the correct idea of them. 1 
volume has been such as to exhaust the hist will also find it v. 
edition in a little over a year and a half 

well for its popularity. — nmericon Journal of tat dently assert that it will I 
Medical Sciences, April, I i 

This little work upon obstetrics will be high 
valued by medical students. We feel <. 



PARTI!?, TIIEOP1I1IA S. )/. />.. /./.. />.. 

Professor of Oh-Jcl in-- 

A Treatise on Midwifery. In one very liar.. I 
pages, with numerous illustration-. In press. 

BARNES, ROBERT, M. !>.. ami I\i\( <)( HI. K />.. 

Phvs. to the Genera! by Obst< ' 

A System of Obstetric Medicine and Suruery, Theoiv; 
ical. For the Student and the Practitioner. Theft 
Prof. Milnes Marshall. In two hand 

BARNES, EA\< Olin. M. />.. 

ObsU vnto st. T! 

A Manual of Midwifery for Midwivos an In one 

royal 12mo. volume of 197 pages, with •".'» Illustration!. < 1 I 

PARRY, JOHN S., )/. />.. 

• ician to thi I 
Extra -Uterine Pregnan liniml II 

Treatment. In one Land- 

TA1HFER, THOMAS HAWKES> K />. 

On the Signs and Diseases of " ' \ 

English edition. In one han.l 
16 woodcuts. Cloth, J 

wnrcKJBL, i\ 

A Complete Pntholo&y ai 

For Students and Practiti ted, with 

second German edition, by Jambb Read ( hadwk «:. H D. [now 

pages. Cloth, $4.00. 



30 



Lea Brothers & Co.'s Publications — Midwfy., r>is. Cliildn. 



LEISHMAN, WILLIAM, M. D., 

Regius Professor of Midwifery in the University of Glasgow, etc. 

A System of Midwifery, Including the Diseases of Pregnancy and the 
Puerperal State. Third American edition, revised by the Author, with additions by 
John S. Parry, M. D., Obstetrician to the Philadelphia Hospital, etc. In one large and 
very handsome octavo volume of 740 pages, with 205 illustrations. Cloth, $4.50 ; leather, 
$5.50 ; very handsome half Russia, raised bands, $6.00. 

The author is broad in his teachings, and dis 
cusses briefly the comparative anatomy of the pel 



vis and the mobility of the pelvic articulations. 
The second chapter is devoted especially to 
the s£udv of the pelvis, while in the third the 
female organs of generation are introduced. 
The structure and development of the ovum are 
admirably described. Then follow chapters upon 
the various subjects embraced in the study of mid- 
wifery. The descriptions throughout the work are 
plain and pleasing. It is sufficient to state that in 
this, the last edition of this well-known work, every 
recent advancement in this field has been brought 
forward. — Physician and Surgeon, Jan. 1880. 

We gladly welcome the new edition of this ex- 
cellent text-book of midwifery. The former edi- 
tions have been most favorably received by the 
profession on both sides of the Atlantic. In the 



preparation of the present edition the author has 
made such alterations as the progress of obstetri- 
cal science seems to require, and we cannot but 
admire the ability with which the task has been 
performed. We consider it an admirable text- 
book for students during their attendance upon 
lectures, and have great pleasure in recommend- 
ing it. As an exponent of the midwifery of the 
present day it has no superior in the English lan- 
guage. — Canada Lancet, Jan. 1880. 

To the American student the work before us 
must prove admirably adapted. Complete in all its 
parts, essentially modern in its teachings, and with 
demonstrations noted for clearness and precision, 
it will gain in favor and be recognized as a work 
of standard merit. The work cannot fail to be 

Sopular and is cordially recommended. — -ZV. O. 
led. and Surg. Journ., March, 1880. 



SMITH, J. LEWIS, 31. D., 

Clinical Professor of Diseases of Children in the Bellevue Hospital Medical College, N. Y. 

A Complete Practical Treatise on the Diseases of Children. Fifth 
edition, thoroughly revised and rewritten. In one handsome octavo volume of 836 pages, 
with illustrations. Cloth, $4.50 ; leather, $5.50 ; very handsome half Russia, raised bands, $6. 

which we venture to say will be a favorable one. — 
Dublin Journal of Medical Science, March, 1883. 

There is no book published on the subjects of 
which this one treats that is its equal in value to 
the physician. While he has said just enough to 
impart the information desired by general practi- 
tioners on such questions as etiology, pathology, 
prognosis, etc., he has devoted more attention to 
the diagnosis and treatment of the ailments which 
he so accurately describes ; and such information 
is exactly what is wanted by the vast majority of 
" family physicians." — Va. Med. Monthly, Feb. 1882. 



This is one of the best books on the subject with 
which we have met and one that has given us 
satisfaction on every occasion on which we have 
consulted it, either as to diagnosis or treatment. 
It is now in its fifth edition and in its present form 
is a very adequate representation of the subject it 
treats of as at present understood. The important 
subject of infant hygiene is fully dealt with in the 
early portion of the book. The great bulk of the 
work is appropriately devoted to the diseases of 
infancy and childhood. We would recommend 
any one in need of information on the subject to 
procure the work and form his own opinion on it, 



KEATING, JOHNM., M. D., 

Lecturer on the Diseases vf Children at the University of Pennsylvania, etc. 

The Mother's Guide in the Management and Feeding of Infants. 

one handsome 12mo. volume of 118 pages. Cloth, $1.00. 

Works like this one will aid the physician im- 
mensely, for it saves the time he is constantly giv- 
ing his patients in instructing them on the sub- 
jects here dwelt upon so thoroughly and prac- 
tically. Dr. Keating has written a practical book, 
has carefully avoided unnecessary repetition, and 
successfully instructed the mother in such details 
of the treatment of her child as devolve upon her. 
He has studiously omitted giving prescriptions, 
and instructs the mother when to call upon the 
doctor, as his duties are totally distinct from hers. 
— American Journal of Obstetrics, October, 1881. 

Dr. Keating has kept clear of the common fault 
of works of this sort, viz., mixing the duties of 
the mother with those proper to the doctor. There 
is the ring of common sense in the remarks about 



In 



the employment of a wet-nurse, about the proper 
food for a nursing mother, about the tonic effects 
of a bath, about the perambulator versus the nurses, 
arms, and on many other subjects concerning 
which the critic might say, "surely this is obvi- 
ous," but which experience teaches us are exactly 
the things needed to be insisted upon, with the rich 
as well as the poor. — London Lancet, January, 28 1882 
A book small in size, written in pleasant style, in 
language which can be readily understood by any 
mother, and eminently practical and safe; in fact 
a book for which we have been waiting a long 
time, and which we can most heartily recommend 
to mothers as the book on this subject. — New Yoik 
Medical Journal and Obstetrical Revieio, Feb. 18S2. 



OWEN, ED3IUNJD, M. B., F. M. C. S., 

Surgeon to the Children's Hospital, Great Ormond St., London. 
Surgical Diseases of Children. In one 12mo. volume. Preparing. See Series 
of Clinical Manuals, page 3. 

WEST, CHARLES, M. D., 

Physician to the Hospital for Sick Children, London, etc. 

Lectures on the Diseases of Infancy and Childhood. Fifth American 
from 6th English edition. In one octavo volume of 686 pages. Cloth, $4.50 ; leather, $5.50. 

By the Same Author. 

On Some Disorders of the Nervous System in Childhood. 
12mo. volume of 127 pages. Cloth, $1.00. 



In one small 



CONDIE'S PRACTICAL TREATISE ON THE 
DISEASES OF CHILDREN. Sixth edition, re- 



vised and augmented. In one octavo volume of 
779 pages. Cloth, $5.25 ; leather, $6.25. 



Lea Brothers & Co.'s Publications — Med. Juris., AOsceL 3] 

TIDY, CHARLES MEYMOTT, M. B.. E. < . 8., 

Professor of Chemistry awl of Forensic Medicine arid Public Health at the London Hospital, 

Legal Medicine. Volume II. Legitimacy and Paternity, 
tion, Rape, Indecent Exposure, - Bestiality, Live Birth, Infant; j \ia, 

Drowning, Hangi ogulation, Suffocation. Making a v. 

tavo volume of 529 pages. CI 

Volume I. Containing 664 imperial octavo pages, with two beautiful colored 
plates. Cloth, $6.00 ; leather, $7.00. 

The satisfaction expressed with the first portion tables of eases appended to each division of the 
of tii is work is in no wise lessened by a perusal 

the second volume. We find it characterized by amount of labor and research, I 
the same fulness of detail and cl< •• of the most valuat.l. 

pression which we had occasion so highly to com- especially for ref< 
mend in our former notice, and which render it so American Journal of the Medical & 
valuable to the medical jurist. The copi' 

TAYLOR, ALFRED 8., M. J).. 

Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital, London. 

A Manual of Medical Jurisprudence. Eighth American from the tenth I 

don edition, thoroughly revised and rewritten. Edited by Jon." M. I >.. I'm feasor 

of Medical Jurisprudence and Toxicology in the Dniversity of Pennsylvania. In <-ne 

large octavo volume of 937 pages, with 70 ill int. loth, $5.00; leather, $6.00; half 

. 6.50. 

The American editions of this standard manual only ha itrican 

have for a long time laid claim to the attention 188L 

the profession in this country: and the eighth This celebrated work has been the standard an* 

dying the latest thoughts thority in its department for thirtv-- 

and emendation.- of Dr. Taylor upon the Bubject both in England and America, 

to which he devoted his life with an assiduity and 8 i on a which ii 

sa which made hirn Jacile princept among j t will 

English writers on medical Jurisprudence. Both simply indisp. 
the author and the hook have made a mark t every liberally-ed 

deep to be affected by criticism, whether it be heartily comirn 

censure or praise. In this ca.se, however, we should ,-. Law Journal, March '2A, U 



By the Same Author. 

The Principles and Practice of Medical Jurisprudence. Third editi 
In two handsome octa? s, containing 1416 page — Illustrations. cl«>th,$10; 

leather, $12. J 

For yean Dr. Taylor was the highest authority matters connected with • 
in England upon the Bubject to which ought up t-> the ■ 

ntion. Hia mplish I 

judgment excellent, and his skill beyond cavil, it suit Dr. St venaon 

\<H that the work of on*- wh( . t intr, bringing it well 

ad an "eno: 

By the Same Author. 
Poisons in Relation to Medical Jurisprudence and Medienu 
American, from the third and re gliah edition. In one large octavo vol 

leather, | 

PXPJPEB, AUGUSTUS ./., M. v., M. /;., /'. //. < . v. 

.■Inn. 

Forensic Medicine, loom 
\. 

i.i :a, ii i:\in (. 

Superstition and For ys on Tho Wager of Lfiw, The Waeor of 

Battle, The Ordeal and 
I I 2mo. volui 



philosopl 

■ 






Studios in Church II 
efit of Clcrgv "' '"• , " 

TheauthoT 

.« • i 

of knowledge and imparl 
compel admii ition. i 

com pre I inb I 

other single volume is the 



Allen's Anatomy .... 

American Journal of the Medical Sciences 
American System of Gynaecology . 
American System of Practical Medicine 
*Ashhurst's Surgery .... 
Ash well on Diseases of Women 
Attfield's Chemistry .... 
Ball on the Rectum and Anus 
Barlow's Practice of Medicine 
Barnes' Midwifery .... 
♦Barnes on Diseases of Women 
Barnes' System of Obstetric Medicine 
Bartholow on Electricity 
Basham on Renal Diseases . 
Bell's Comparative Physiology and Anatomy 
Bellamy's Operative Surgery 
Bellamy's Surgical Anatomy 
Blandford on Insanity 
Bloxam's Chemistry .... 
Bowman's Practical Chemistry 
*Bristowe's Practice of Medicine . 
Broadbent on the Pulse 
Browne on the Ophthalmoscope 
Browne on the Throat 
Bruce's Materia Medica and Therapeutics 
Brunton's Materia Medica and Therapeutics 
Bryant on the Breast .... 
♦Bryant's Practice of Surgery 
" Di 



*Bumstead on Venereal 

*Burnett on the Ear .... 

Butlin on the Tongue .... 

Carpenter on the Use and Abuse of Alcohol 

♦Carpenter's Human Physiology . 

Carter on the Eye .... 

Century of American Medicine 

Chambers on Diet and Regimen 

Charles' Physiological and Pathological Chem 

Churchill on Puerperal Fever 

Clarke and Lockwood's Dissectors' Manual 

Classen's Quantitative Analysis 

Cleland's Dissector .... 

Clouston on Insanity .... 

Clowes' Practical Chemistry 

Coats' Pathology .... 

Cohen on the Throat .... 

Coleman's Dental Surgery 

Condie on Diseases of Children 

Cooper's Lectures on Surgery 

Cornil on Syphilis .... 

*Cornil and Ranvier's Pathological Histology 

Cullerier's Atlas of Venereal Diseases 

Curnow's Medical Anatomy 

Dalton on the Circulation 

*Dalton's HumanPhysiology 

Dalton's Topographical Anatomy of the Brain 

Davis' Clinical Lectures 

Draper's Medical Physics 

Druitt's Modern Surgery 

Duncan on Diseases of Women 

*Dunglison's Medical Dictionary . 

Edis on Diseases of Women . 

Ellis' Demonstrations of Anatomy 

Emmet's Gynaecology 

*Erichsen's System of Surgery 

Esmarch's Early Aid in Injuries and Accid'ts 

Farquharson's Therapeutics and Mat. Med. 

Fenwick's Medical Diagnosis 

Finlayson's Clinical Diagnosis 

Flint on Auscultation and Percussion 

Flint on Phthisis .... 

Elint on Physical Exploration of the Lungs 

Flint on Respiratory Organs 

Flint on the Heart .... 

♦Flint's Clinical Medicine 

Flint's Essays . 

♦Flint's Practice of Medicine 

Folsom's Laws of U. S. on Custody of Insane 

Foster's Physiology .... 

♦Fothergill's Handbook of Treatment 

Fownes' Elementary Chemistry .. 

Fox on Diseases of the Skin . 

Frankland and Japp's Inorganic Chemistry 

Fuller on the Lungs and Air Passages 

Galloway's Analysis .... 

Gibney's Orthopaedic Surgery 

Gibson's Surgery .... 

Gluge's Pathological Histology, by Leidy 

Gould's Surgical Diagnosis . 

♦Gray's Anatomy ..... 

Greene's Medical Chemistry . 

Green's Pathology and Morbid Anatomy 

Griffith's Universal Formulary 

Gross on Foreign Bodies in Air-Passages 

Gross on Impotence and Sterility . 

Gross on Urinary Organs 

♦Gross' System of Surgery . 

Habershon on the Abdomen 

♦Hamilton on Fractures and Dislocations 

Hamilton on Nervous Diseases 

Hartshorne's Anatomy and Physiology . 

Hartshorne's Conspectus of the Med. Sciences 

Hartshorne's Essentials of Medicine 

Hermann's Experimental Pharmacology 

Hill on Syphilis ..... 

Hillier's Handbook of Skin Diseases 

Hoblyn's Medical Dictionary 

Hodge on Women .... 



3 

27 
15 
20 
28 

9 
21 
17 
29 
27 
29 
17 
24 
3,7 
3,20 

6 
19 

9 

9 
14 
3,16 
23 
18 
11 
11 
3,21 
21 
25 
24 



7 
16 

7 
21 
28 

4 
27 

7 

2S 
21 
21 
12 
16 
16 
18 
18 
18 
18 
18 
16 
16 
14 
19 

8 
16 

8 
26 

8 
18 

9 
20 
20 
13 
3,20 

5 
10 
13 
11 
18 
25 
24 
20 
17 
23 
19 

6 

3 
14 
11 
25 
26 

4 
28 



Hodge's Obstetrics .... 

Hoffmann and Power's Chemical Analysis 

Holden's Landmarks .... 

Holland's Medical Notes and Reflections 

♦Holmes' System of Surgery 

Horner's Anatomy and Histology 

Hudson on Fever .... 

Hutchinson on Syphilis . . . 

Hyde on the Diseases of the Skin . 

Jones (C. Handheld) on Nervous Disorders 

Juler's Ophthalmic Science and Practice 

Keating on Infants .... 

King's Manual of Obstetrics . 

Klein's Histology .... 

La Roche on Pneumonia, Malaria, etc. . 

La Roche on Yellow Fever . 

Laurence and Moon's Ophthalmic Surgery 

Lawson on the Eye, Orbit and Eyelid 

Lea's Studies in Church History 

Lea's Superstition and Force 

Lee on Syphilis ..... 

Lehmann f s Chemical Physiology . 

♦Leishman's Midwifery 

Lucas on Diseases of the Urethra . 

Ludlow's Manual of Examinations 

Lyons on Fever ..... 

Maisch's Organic Materia Medida . 

Marsh on the Joints .... 

Medical News ..... 

Meigs on Childbed Fever 

Miller's Practice of Surgery . 

Miller's Principles of Surgery 

Mitchell's Nervous Diseases of Women . 

Morris on Diseases of the Kidneys 

Morris on Skin Diseases 

Neill and Smith's Compendium of Med. Sci. 

Nettleship on Diseases of the Eye . 

Owen on Diseases of Children 

♦Parrish's Practical Pharmacy 

Parry on Extra-Uterine Pregnancy 

Parvin's Midwifery .... 

Pavy on Digestion and its Disorders 

Pepper's Forensic Medicine . 

Pepper's Surgical Pathology 

Pick on Fractures and Dislocations 

Pirrie's System of Surgery 

Playfair on Nerve Prostration and Hysteria 

♦Playfair's Midwifery .... 

Politzer on the Ear and its Diseases 

Power's Human Physiology . 

Ralfe's Clinical Chemistry 

Ramsbotham on Parturition 

Remsen's Theoretical Chemistry . 

♦Reynolds' System of Medicine 

Richardson's Preventive Medicine 

Roberts on Urinary Diseases 

Roberts' Principles and Practice of Surgery 

Robertson's Physiological Physics 

Rodwell's Dictionary of Science 

Sargent's Minor and Military Surgery 

Savage on Insanity, including Hysteria . 

Schafer's Histology .... 

Schreiber on Massage .... 

Seiler on the Throat, Nose and Naso-Pharynx 

Series of Clinical Manuals 

Simon's Manual of Chemistry 

Skey's Operative Surgery 

Slade on Diphtheria .... 

Smith (Edward) on Consumption . 

Smith (H. H.) and Horner's Anatomical Atlas 

♦Smith (J. Lewis) on Children 

♦Stille & Maisch's National Dispensatory 

♦Still6's Therapeutics and Materia Medica 

Stimson on Fractures .... 

Stimson's Operative Surgery 

Stokes on Fever ..... 

Students' Series of Manuals . 

Sturges' Clinical Medicine . 

Tanner on Signs and Diseases of Pregnancy 

Tanner's Manual of Clinical Medicine . 

Tarnier and Chantreuil's Obstetrics 

Taylor on Poisons .... 

♦Taylor's Medical Jurisprudence . 

Taylor's Prin. and Prac. of Med. Jurisprudence 

♦Thomas on Diseases of Women . 

Thompson on Stricture 

Thompson on Urinary Organs 

Tidy's Legal Medicine .... 

Todd on Acute Diseases 

Treves' Applied Anatomy 

Treves on Intestinal Obstruction . 

Tuke on the Influence of Mind on the Body 

Walshe on the Heart .... 

Watson's Practice of Physic . 

Watts' Physical and Inorganic Chemistry 

♦Wells on 'the Eye .... 

West on Diseases of Childhood 

West on Diseases of Women 

West on Nervous Disorders in Childhood 

Williams on Consumption . 

Wilson's Handbook of Cutaneous Medicine 

Wilson's Human Anatomy . 

Winckel on Pathol, and Treatment of Childbed 

Wohler's Organic Chemistry . . 

Woodhead's Practical Pathology . 

Year-Book of Treatment 



Books marked * are also bound in half Russia. 



LEA BROTHERS & CO., Philadelphia, 



: 



K 



